Zeno Kupper

Hopelessness and its impact on rehabilitation outcome in schizophrenia –an exploratory study

The primary focus in contemporary psychiatry on symptoms and their neurobiological basis, although fundamentally important, is nevertheless incomplete. The long-term course and outcome of schizophrenia are determined not only by the disorder, but also by the interaction between the person and the disorder. Not only psychopathological symptoms but also cognitive variables such as negative self-concepts, low expectations and external loci of control can influence the patients coping strategies and may lead to hopelessness and chronicity. Hopelessness here refers to a cognitive-affective state in which the patient perceives the disorder and its consequences to be beyond his control, feels helpless and has given up expecting to influence its course positively, thereby abandoning responsibility and active coping strategies. In a prospective study, we examined these relationships by using logistic regression in data from 46 schizophrenic outpatients who were participating in a vocational rehabilitation program. Negative self-concepts, external loci of control, and depression correlated to a higher extent with depressive-resigned coping strategies than did schizophrenic symptoms. Thus, poor rehabilitation outcome may be predicted to a high degree by the presence of external loci of control, pessimistic outcome expectancies, negative symptoms, and depressive-resigned coping strategies. After having eliminated the influence of negative symptoms, external control beliefs still had significant predictive value for the outcome. Rehabilitation outcome in schizophrenic patients can be only partially predicted by negative symptoms; the other predictive factor is whether the patient has already given up or not.

Long-term effectiveness of supported employment: 5-year follow-up of a randomized controlled trial.

OBJECTIVE The individual placement and support model of supported employment has been shown to be more effective than other vocational approaches in improving competitive work over 1-2 years in persons with severe mental illness. The authors evaluated the longer-term effects of the model compared with traditional vocational rehabilitation over 5 years. METHOD A randomized controlled trial compared supported employment to traditional vocational rehabilitation in 100 unemployed persons with severe mental illness. Competitive work and hospital admissions were tracked for 5 years, and interviews were conducted at 2 and 5 years to assess recovery attitudes and quality of life. A cost-benefit analysis compared program and total treatment costs to earnings from competitive employment. RESULTS The beneficial effects of supported employment on work at 2 years were sustained over the 5-year follow-up period. Participants in supported employment were more likely to obtain competitive work than those in traditional vocational rehabilitation (65% compared with 33%), worked more hours and weeks, earned more wages, and had longer job tenures. Reliance on supported employment services for retaining competitive work decreased from 2 years to 5 years for participants in supported employment. Participants were also significantly less likely to be hospitalized, had fewer psychiatric hospital admissions, and spent fewer days in the hospital. The social return on investment was higher for supported employment participants, whether calculated as the ratio of work earnings to vocational program costs or of work earnings to total vocational program and mental health treatment costs. CONCLUSIONS The results demonstrate that the greater effectiveness of supported employment in improving competitive work outcomes is sustained beyond 2 years and suggest that supported employment programs contribute to reduced hospitalizations and produce a higher social return on investment.

Relationships between social competence, psychopathology and work performance and their predictive value for vocational rehabilitation of schizophrenic outpatients

Earlier studies suggest that social competence has a higher predictive value for vocational outcome than psychopathology. These studies, however, show methodological shortcomings, including the fact that the instruments used for assessing social competence, psychopathology and work performance are strongly interrelated. The present study, involving a population of 34 chronically schizophrenic outpatients enrolled in a vocational rehabilitation program, was conducted in order to determine: (1) how closely the Role Play Test, the Positive and Negative Syndrome Scale and the Work Behavior Assessment Scale are related to each other; and (2) whether social competence is a better predictor of work performance and outcome of vocational rehabilitation than psychopathology. Factor analysis has revealed that the instruments are interrelated, mainly in the dimensions of negative symptoms, social relationships, non-verbal measures of social competence and conceptual disorganization. In backward regression analyses, psychopathological indicators proved to be the best predictors of work performance both cross-sectionally as well as in the longterm course. In the traditional two-syndrome model of schizophrenic psychopathology only negative symptoms were left in the regression model. In a four-dimension model the disorder of relating and the conceptual disorganization dimension were the best predictors. Differences between disorder of relating and social competence, assessed by the Role Play Test, are discussed here as well as the implications of this study for rehabilitation.

Predicting vocational functioning and outcome in schizophrenia outpatients attending a vocational rehabilitation program.

Abstract.Background: Vocational rehabilitation is a central issue in the rehabilitation of patients with chronic schizophrenia. However, even with the help of comprehensive integration programs, achieving this objective remains a very ambitious and difficult undertaking. Therefore, a profound and up-to-date knowledge of vocational functioning and outcome predictors in patients who have the goal to return into competitive employment is imperative. The objective of the present study was to test the predictors summarized in the recent review of Cook and Razzano [1], as well as to test those predictors specified in the nine hypotheses put forward by Anthony and Jansen [2] in schizophrenia patients enrolled in a vocational rehabilitation program. Methods: The predictive value of ten hypotheses centering on vocational functioning and outcome were consecutively tested in a sample of 53 schizophrenia patients. Those predictors identified as significant were then taken into a ‘winner take all’ regression in order to determine which of them were the best. Results: The overall work performance observed in a workshop proved to be the best predictor of vocational functioning. Contrary to the pivotal claim in Anthony and Jansens review, in our sample, negative symptoms indeed influenced vocational functioning, outcome and functional skills. Cognitive impairments, social competence and fatalistic control beliefs also had predictive value for vocational functioning and outcome. Conclusions: These results reflect the accumulated findings of the past decade as summarized by Cook and Razzano. Moreover, they serve to substantiate the necessity of promoting the concept of cognitive remediation and associated programs designed to transform fatalistic beliefs into feelings of hopefulness, thereby enhancing the readiness of schizophrenia patients to enroll in rehabilitation programs.

A randomised controlled trial of the efficacy of supported employment.

Hoffmann H, Jäckel D, Glauser S, Kupper Z. A randomised controlled trial of the efficacy of supported employment.

Video-based quantification of body movement during social interaction indicates the severity of negative symptoms in patients with schizophrenia

In schizophrenia, nonverbal behavior, including body movement, is of theoretical and clinical importance. Although reduced nonverbal expressiveness is a major component of the negative symptoms encountered in schizophrenia, few studies have objectively assessed body movement during social interaction. In the present study, 378 brief, videotaped role-play scenes involving 27 stabilized outpatients diagnosed with paranoid-type schizophrenia were analyzed using Motion Energy Analysis (MEA). This method enables the objective measuring of body movement in conjunction with ordinary video recordings. Correlations between movement parameters (percentage of time in movement, movement speed) and symptom ratings from independent PANSS interviews were calculated. Movement parameters proved to be highly reliable. In keeping with predictions, reduced movement and movement speed correlated with negative symptoms. Accordingly, in patients who exhibited noticeable movement for less than 20% of the observation time, prominent negative symptoms were highly probable. As a control measure, the percentage of movement exhibited by the patients during role-play scenes was compared to that of their normal interactants. Patients with negative symptoms differed from normal interactants by showing significantly reduced head and body movement. Two specific positive symptoms were possibly related to movement parameters: suspiciousness tended to correlate with reduced head movement, and the expression of unusual thought content tended to relate to increased movement. Overall, a close and theoretically meaningful association between the objective movement parameters and the symptom profiles was found. MEA appears to be an objective, reliable and valid method for quantifying nonverbal behavior, an aspect which may furnish new insights into the processes related to reduced expressiveness in schizophrenia.

Facilitators of psychosocial recovery from schizophrenia

Using a sample of 75 patients with schizophrenia enrolled in the Bern, Switzerland community psychiatry program, we aimed to identify factors that may facilitate recovery in schizophrenia. Factors facilitating recovery from schizophrenia were culled from the published literature as well as from our research on rehabilitation. Data on facilitators from 20 patients who had good rehabilitation outcomes and were identified as having recovered were contrasted with the same dimensions for the other 55 patients in our cohort. Case studies of four patients from our vocational rehabilitation program who fulfilled the criteria for recovery were used to identify facilitators that appeared to be relevant in their recovery process. At intake into our vocational rehabilitation program, the group of participants with good rehabilitation outcomes had significantly less negative symptoms, lower levels of disability and lower ratings on external locus of control. Compared to the majority of the other participants, the recovered patients had a more favourable profile in all five areas of facilitators of recovery. However, it was not possible to predict the extent or rapidity of recovery on the basis of patient characteristics at the start of their rehabilitation. Recovery was not a consistent pattern but rather appeared to be a process that varied in degree from person to person and also within each individual over time. Given the difficulty of predicting recovery, it is incumbent upon mental health professionals to extend the full spectrum of recovery-oriented services to all patients.

Nonverbal synchrony in social interactions of patients with schizophrenia indicates socio-communicative deficits

Background Disordered interpersonal communication can be a serious problem in schizophrenia. Recent advances in computer-based measures allow reliable and objective quantification of nonverbal behavior. Research using these novel measures has shown that objective amounts of body and head movement in patients with schizophrenia during social interactions are closely related to the symptom profiles of these patients. In addition to and above mere amounts of movement, the degree of synchrony, or imitation, between patients and normal interactants may be indicative of core deficits underlying various problems in domains related to interpersonal communication, such as symptoms, social competence, and social functioning. Methods Nonverbal synchrony was assessed objectively using Motion Energy Analysis (MEA) in 378 brief, videotaped role-play scenes involving 27 stabilized outpatients diagnosed with paranoid-type schizophrenia. Results Low nonverbal synchrony was indicative of symptoms, low social competence, impaired social functioning, and low self-evaluation of competence. These relationships remained largely significant when correcting for the amounts of patients‘ movement. When patients showed reduced imitation of their interactants’ movements, negative symptoms were likely to be prominent. Conversely, positive symptoms were more prominent in patients when their interaction partners’ imitation of their movements was reduced. Conclusions Nonverbal synchrony can be an objective and sensitive indicator of the severity of patients’ problems. Furthermore, quantitative analysis of nonverbal synchrony may provide novel insights into specific relationships between symptoms, cognition, and core communicative problems in schizophrenia.

Time-Series Panel Analysis (TSPA) - Multivariate modeling of temporal associations in psychotherapy process.

OBJECTIVE Processes occurring in the course of psychotherapy are characterized by the simple fact that they unfold in time and that the multiple factors engaged in change processes vary highly between individuals (idiographic phenomena). Previous research, however, has neglected the temporal perspective by its traditional focus on static phenomena, which were mainly assessed at the group level (nomothetic phenomena). To support a temporal approach, the authors introduce time-series panel analysis (TSPA), a statistical methodology explicitly focusing on the quantification of temporal, session-to-session aspects of change in psychotherapy. TSPA-models are initially built at the level of individuals and are subsequently aggregated at the group level, thus allowing the exploration of prototypical models. METHOD TSPA is based on vector auto-regression (VAR), an extension of univariate auto-regression models to multivariate time-series data. The application of TSPA is demonstrated in a sample of 87 outpatient psychotherapy patients who were monitored by postsession questionnaires. Prototypical mechanisms of change were derived from the aggregation of individual multivariate models of psychotherapy process. In a 2nd step, the associations between mechanisms of change (TSPA) and pre- to postsymptom change were explored. RESULTS TSPA allowed a prototypical process pattern to be identified, where patients alliance and self-efficacy were linked by a temporal feedback-loop. Furthermore, therapists stability over time in both mastery and clarification interventions was positively associated with better outcomes. CONCLUSIONS TSPA is a statistical tool that sheds new light on temporal mechanisms of change. Through this approach, clinicians may gain insight into prototypical patterns of change in psychotherapy.

Effects of Sustained Competitive Employment on Psychiatric Hospitalizations and Quality of Life

OBJECTIVE There is extensive evidence for the effectiveness of supported employment among people with severe mental illness. However, less research has been conducted to evaluate the effects of sustained competitive employment on nonvocational outcomes. The aim of this study was to evaluate the effects of sustained competitive work on quality of life and psychiatric hospitalizations. METHODS As part of a randomized controlled trial, a mediation analysis was used to compare the direct and indirect effects of supported employment versus a traditional vocational program on sustained competitive employment, days of psychiatric hospitalization, and quality of life among 85 participants over five years. RESULTS The five-year follow-up indicated that the effects of supported employment on reduced days of hospitalization and increased quality of life were fully mediated by the programs effects on increasing sustained competitive employment. CONCLUSIONS The rehabilitative and therapeutic dimensions of functional health conditions are interrelated in the long term. The achievement of sustained competitive employment may be a key factor in improving social and psychiatric outcomes for people with severe and persistent mental disorders.