Wayne Zito

Neurocognitive enhancement therapy with vocational services: Work outcomes at two-year follow-up

UNLABELLED Neurocognitive enhancement therapy (NET) is a remediation program for the persistent and function-limiting cognitive impairments of schizophrenia. In a previous study in veterans, NET improved work therapy outcomes as well as executive function and working memory. The present study aimed to determine whether NET could enhance functional outcomes among schizophrenia and schizoaffective patients in a community mental health center receiving community-based vocational services. METHOD Patients (N=72) participated in a hybrid transitional and supported employment program (VOC) and were randomized to either NET+VOC or VOC only. NET+VOC included computer-based cognitive training, work feedback and a social information information-processing group. VOC only also included two weekly support groups. Active intervention was 12 months with 12 month follow-up. Follow-up rate was 100%. RESULTS NET+VOC patients worked significantly more hours during the 12 month follow-up period, reached a significantly higher cumulative rate of competitive employment by the sixth quarter, and maintained significantly higher rates of employment. CONCLUSION NET training improved vocational outcomes, suggesting the value of combining cognitive remediation with other rehabilitation methods to enhance functional outcomes.

Social skills at work. Deficits and predictors of improvement in schizophrenia.

While the impact of social learning programs upon social deficits in schizophrenia has been widely studied, less is understood about which patients have the poorest social skills, and among those which patients have deficits most refractory to rehabilitation. To explore these questions, this study compared the symptom levels and performance on neuropsychological testing of 91 subjects with impaired and unimpaired social skills enrolled in a vocational rehabilitation program. After 10 weeks of rehabilitation and a supportive group treatment, social skills among a subsample of 41 subjects with initially impaired social skills were reassessed. Results indicate that subjects with initially impaired social skills had significantly higher levels of negative symptoms. However, multiple regression analysis revealed that cognitive impairments at intake, rather than level of negative symptoms, predicted improvement among subjects with initially impoverished social skills (R2 = .35). Results suggest that level of cognitive impairment is associated with the persistence of social skills deficits in schizophrenia. —J Nerv Ment Dis 183:688–692, 1995

Improved cognitive function in schizophrenia after one year of cognitive training and vocational services.

A year-long program of Neurocognitive Enhancement Therapy (NET) was used to remediate cognitive deficits in people with schizophrenia who were participating in a vocational program. Seventy-two stable outpatients with schizophrenia or schizoaffective disorder, recruited from an urban community mental health center were randomly assigned to a twelve-month vocational program (VOC) or NET+VOC. The vocational program had characteristics of individual placement and support (IPS) programs but also included transitional funding. NET included computer-based cognitive training exercises, a social information processing group and a work feedback group. Sixty-two participants completed a neuropsychological test battery before and after treatment. After one year of treatment, participants receiving NET+VOC had significantly greater improvements on measures of executive function and working memory than did participants in the VOC only condition. Augmenting vocational services with a multifaceted cognitive remediation program may improve cognition in participants with schizophrenia or schizoaffective disorder.

The frequency of associations between positive and negative symptoms and dysphoria in schizophrenia

Weekly assessments of depression, anxiety, and positive and negative symptoms were performed on 80 subjects with schizophrenia or schizoaffective disorder. Using procedures previously reported in another study, the frequency of significant correlations between the sum of anxiety and depression ratings and positive symptoms was compared with the frequency of significant correlations between the sum of anxiety and depression ratings and negative symptoms. Results confirm that dysphoria in schizophrenia tends to be more frequently associated with positive versus negative symptoms, regardless of diagnostic subtype or symptom type. This provides further evidence of the independence of negative symptoms from dysphoria and suggests that the level of positive symptoms and level of dysphoria may mutually influence one another.

The work behavior inventory: A scale for the assessment of work behavior for clients with severe mental illness

Method: Patients presenting for the first time to a psychiatric service who fulfilled DSM-IV criteria for schizophrenia or schizophreniform psychosis were included. Assessments included; Quality of Life Scale (QLS), Positive and Negative Syndrome Scale (PANSS), Global Assessment of Functioning Scale (GAF) and the Structured Clinical Interview for DSM-IV diagnosis (SCID). Duration of untreated psychosis was ascertained by interviews with the patients and their family members (Beiser scale) . Results: Forty six pat ients (35M,llF) with a mean age of 25.6 years (sd 7.6) were included in the study. Mean total QLS score was 60.8 (sd 23.0). The mean total PANSS score was 92.2 (sd 18.6) and the mean GAF score was 19.9 (sd 6.4) . Multiple stepwise regression indicated that QLS was independent of gender and age but, was significantly (p =0.04) related to duration of untreated illness and the presence of an Axis II diagnosis (p=O.04). There was some evidence (p=0.08S) of an association with PANSS score. Conclusion: Quality of life among first presentation schizophrenia/schizophreniform patients is largely determined by the amount of time that elapses between onset and presentation for treatment.

Neurocognitive Enhancement Therapy and Competitive Employment in Schizophrenia: Effects on Clients with Poor Community Functioning

Neurocognitive enhancement therapy (NET) has been shown to improve executive function and working memory and to improve work therapy outcomes. The current study applied NET to a vocational program (VOC) in the community that included transitional funds with supported employment. NET + VOC achieved higher rates of competitive employment and more total hours worked during the 12-month follow-up period, This report examines the relationship between community function at intake and vocational outcomes by condition. Method: 72 outpatients with diagnoses of schizophrenia or schizoaffective disorder were evaluated on Heinrichs Quality of Life Scale and randomized to NET + VOC or to VOC only. Active intervention was 12 months with 12-month follow-up. Follow-up rate was 100% for the intent-to-treat sample. Results: When the sample was divided into higher and lower community functioning, logistic regression found significant effects for level of community function and for condition. Most of the difference between condition was found for poor functioning patients. Only 11.1% of VOC-only clients with poor community function became competitively employed as compared to 60% of NET + VOC clients with poor community function. NET + VOC clients with poor community functioning worked twice as many hours as VOC-only clients with poor community functioning (p < .05). Higher community function clients had competitive employment rates over 60% regardless of condition, and there was no difference in total hours worked. Conclusion: Findings indicate that NET training improved vocational outcomes, but its greatest impact was for clients with poor community functioning. While clients with better community functioning may be able to obtain employment with work services without NET, augmenting conventional services with cognitive remediation may be particularly important to improve vocational outcomes for patients with poor community functioning.

Integrated versus sealed-over recovery in schizophrenia: BORRTI and executive function.

Ego functioning of 222 outpatients with a diagnosis of schizophrenia or schizoaffective disorder was evaluated using the Bell Object Relations and Reality Testing Inventory (BORRTI). Sixty-one of these had BORRTI profiles identified as sealed-over recovery style, and 36 had profiles interpreted as integrated recovery style. Groups were compared on demographic characteristics, symptom profiles, and the Wisconsin Card Sorting Test, a performance measure of executive function. Groups had comparably low levels of positive symptoms, but the integrated recovery group had higher scores on the BORRTI uncertainty of perception scale. The integrated recovery group had significantly fewer minority patients, higher IQ, and higher levels of emotional discomfort. The sealed-over recovery group had higher levels of cognitive disorganization. When differences in ethnicity and IQ were controlled for, the integrated recovery group had better executive functioning. Wisconsin Card Sorting Test categories completed emerged as the significant predictor in a logistic regression, explaining 19% of the variance. These findings support the discriminant validity of these two recovery styles and reveal the importance of executive function in a recovery style that allows for investment in relationships, affect tolerance, and acknowledgment of symptoms.

Cognitive impairment and substance abuse history as predictors of the temporal stability of negative symptoms in schizophrenia.

Research has not consistently indicated that negative symptoms in schizophrenia are temporally stable. One possible explanation for this is that stable negative symptoms are a characteristic of only some individuals with schizophrenia. The current study explored whether cognitive impairment and stimulant abuse history were associated with amount of change in negative symptom level over a 1-year period. Results indicated that among 72 subjects with schizophrenia, performance on the Wisconsin Card Sorting Test and history of stimulant abuse significantly accounted for 18% of the variance in symptom variability after age, intelligence quotient, and initial symptom severity were controlled. As hypothesized, poorer performance on the Wisconsin Carding Sorting Test was associated with less symptom variability, whereas a more extensive stimulant abuse history was associated with greater variability. A discriminant function analysis was able to correctly classify 96% of subjects as having stable symptoms but only 30% as having unstable symptoms indicating a sensitive, but not specific, classification. This finding suggests that cognitive deficits may be a necessary but insufficient condition for temporal stability of negative symptoms and that negative symptoms in schizophrenia are a complex phenomenon best understood in the context of other features of illness and psychosocial variables.

Predictors of on-site vocational support for people with schizophrenia in supported employment.

This study examined predictors of intensity of vocational specialist support for clients with schizophrenia or schizoaffective disorder in supported employment. Sixty-nine outpatients with schizophrenia or schizoaffective disorder were recruited from a community mental health center for 12 months of vocational and cognitive rehabilitation. Neuropsychological test scores, symptom ratings, illness severity, and employment history were used to predict vocational support intensity, expressed as hours coached in ratio to total hours worked over 12 months for each client. Weekly work hours were inversely correlated with intensity of vocational support. Half of the sample averaged 10 to 40 h of work per week and received significantly lower proportions of on-site job coaching than the lowest quartile, which averaged 2 to 5 h of work per week. Regressions predicting support intensity from neuropsychological composite scores, educational/vocational, and hospitalization history were not significant. Significant regressions included PANSS, SANS, and SAPS subscales, after which individual symptoms responsible for explained variance were isolated. SANS social inattention and PANSS active avoidance together predicted 23% of the variance in support intensity. A one-way ANOVA comparing work participation quartiles on these symptoms revealed significantly higher levels of active avoidance and social inattention for participants working less than 10 h per week. A profile emerged of the high intensity client as a socially inattentive or avoidant individual requiring a limited work schedule. Results suggest that these clients require more specialist contact because of failure to adequately engage natural supports at work.