Wendy N. Tenhula

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.

A Randomized, Controlled Trial of Computer-Assisted Cognitive Remediation for Schizophrenia

OBJECTIVE There is considerable interest in cognitive remediation for schizophrenia, but its essential components are still unclear. The goal of the current study was to develop a broadly targeted computer-assisted cognitive remediation program and conduct a rigorous clinical trial in a large group of schizophrenia patients. METHOD Sixty-nine people with schizophrenia or schizoaffective disorder were randomly assigned to 36 sessions of computer-assisted cognitive remediation or an active control condition. Remediation broadly targeted cognitive and everyday performance by providing supportive, graduated training and practice in selecting, executing, and monitoring cognitive operations. It used engaging computer-based cognitive exercises and one-on-one training. A total of 61 individuals (34 in remediation group, 27 in control group) engaged in treatment, completed posttreatment assessments, and were included in intent-to-treat analyses. Primary outcomes were remediation exercise metrics, neuropsychological composites (episodic memory, working memory, attention, executive functioning, and processing speed), and proxy measures of community functioning. RESULTS Regression modeling indicated that performance on eight of 10 exercise metrics improved significantly more in the remediation condition than in the control condition. The mean effect size, favoring the remediation condition, was 0.53 across all 10 metrics. However, there were no significant benefits of cognitive remediation on any neuropsychological or functional outcome measure, either immediately after treatment or at the 3-month follow-up. CONCLUSIONS Cognitive remediation for people with schizophrenia was effective in improving performance on computer exercises, but the benefits of training did not generalize to broader neuropsychological or functional outcome measures. The evidence for this treatment approach remains mixed.

The token economy for schizophrenia: review of the literature and recommendations for future research.

The token economy is a treatment intervention based on principles of operant conditioning and social learning. Developed in the 1950s and 1960s for long-stay hospital patients, the token economy has fallen out of favor since that time. The current review was undertaken as part of the 2003 update of the schizophrenia treatment recommendations of the Patient Outcomes Research Team (PORT). A total of 13 controlled studies of the token economy were reviewed. As a group, the studies provide evidence of the token economys effectiveness in increasing the adaptive behaviors of patients with schizophrenia. Most of the studies are limited, however, by methodological shortcomings and by the historical context in which they were performed. More research is needed to determine the specific benefits of the token economy when administered in combination with contemporary psychosocial and psychopharmacological treatments.

Preliminary reliability and validity of the clinician-administered PTSD Scale for schizophrenia

This study provides preliminary psychometric support for a version of the Clinician-Administered Posttraumatic Stress Disorder (PTSD) Scale (CAPS; D. D. Blake et al., 1990) adapted for use with patients with schizophrenia (CAPS-S; J. S. Gearon. S. Thomas-Lohrman, & A. S. Bellack, 2001). Nineteen women with schizophrenia and co-occurring illicit drug use disorders were administered the CAPS-S, the Structured Clinical Interview for DSM-IV diagnoses (SCID). and scales measuring trauma-related psychopathology. The results indicate that the CAPS-S can distinguish between those with and without PTSD and that the symptom clusters measure unified constructs. Interrater and test-retest reliability were high for PTSD diagnosis and symptom clusters. Solid convergent validity was demonstrated between the CAPS-S and SCID-based PTSD diagnoses and the Impact of Event Scale. There is also preliminary evidence of discriminant validity. These results support the use of the CAPS-S in women with schizophrenia.

Is learning potential associated with social skills in schizophrenia

Cognitive deficits are a primary factor in the social and functional impairments characteristic of schizophrenia and an important predictor of treatment success in psychosocial rehabilitation. This study examined the association between abstract reasoning and social functioning by assessing whether learning potential on the Wisconsin Card Sorting Test (WCST) relates to changes in social competence following social skills training (SST). Fifty-six veterans with schizophrenia or schizoaffective disorder completed a series of assessments followed by eight SST sessions. To evaluate learning potential, we assessed participants with the WCST and Category Test (CT), taught them a training protocol for the WCST, and retested on both measures. Participants learned the WCST, generalized this learning to improve their performance on the CT, and retained these gains for several weeks. Participants showed small improvements on the Maryland Assessment of Social Competence (MASC), but WCST learning potential and CT generalization were unrelated to improvement on the MASC.

Behavioral Treatment of Substance Abuse in Schizophrenia

Co-occurring substance use disorders are highly prevalent among individuals with schizophrenia and other serious and persistent mental illnesses (SPMI) and are associated with clinically significant consequences. A multifaceted behavioral treatment called Behavioral Treatment for Substance Abuse in Serious and Persistent Mental Illness (BTSAS) can reduce substance abuse in persons with SPMI. The key treatment strategies in BTSAS include a urinalysis contingency, short-term goal setting, training in drug refusal skills, psychoeducation about the impact of drug use, and relapse prevention training. A case example illustrating the application of BTSAS is presented and relevant clinical issues are discussed.

Employment Interventions for Persons with Mood and Anxiety Disorders

The occupational disability associated with mood and anxiety disorders has been receiving increasing attention from mental health and occupational researchers and practitioners, leading to the development of several work-focused interventions for these conditions. This is clearly an emerging area of research that has yet to define the critical intervention to remedy this substantial problem. This chapter describes the existing interventions with an eye toward highlighting applications to current rehabilitation and mental health practice but also the need for further development in this area. In order to provide some context, we begin first with a brief description of mood and anxiety disorders, their impact on work functioning (we refer the reader to chapters by Wald (2011) and by Lerner et al. (2011), this volume, for a more detailed discussion of these issues) and a summary of optimal treatment for these disorders. Next, we review several work-based interventions, including their key elements and available data on their effectiveness. We have organized these work-based interventions into three categories: individual level (those delivered to the individual employee), organization level (those delivered company-wide), and combined (those that combine both types). Finally, we identify common treatment foci of these interventions and how these may inform current practice.

Assessment of vocational functioning in serious mental illness: A review of situational assessment and performance based measures

There has been an intensified focus on assessment of community functioning in individuals with serious mental illness (SMI). Several reviews of functional measures for SMI have been published, yet the assessment of vocational functioning has received limited attention. The purpose of this review was to describe existing measures of vocational functioning developed for individuals with SMI. Twelve measures were identified: 9 situational assessments and 3 performance based measures. Information on the development, intended purpose, administration and psychometric properties of each measure was compiled from published reports. To further evaluate and compare these measures they were each rated on 4 criteria: practicality, reliability, validity, and comprehensiveness. Results indicated that no single measure emerged as superior across all criteria. Most measures had adequate reliability and tended to be well validated, particularly those developed in a research context, while situational assessments had greater practicality. Few measures provided information on their sensitivity to change as a result of intervention. Suggestions for use of specific measures for clinical assessment and outcome evaluation purposes are presented. Challenges to implementation of these measures in contemporary vocational rehabilitation settings are identified and the need for further research in this area is highlighted.