A randomized controlled trial of long-acting injectable risperidone vs continuation on oral atypical antipsychotics for first-episode schizophrenia patients: initial adherence outcome.

OBJECTIVE: Nonadherence for first-episode schizophrenia is a major unsolved challenge. The long-acting injectable route is an appealing strategy, but there are concerns about acceptability. We report on acceptance and initial adherence outcomes with risperidone long-acting injection (RLAI) in first-episode schizophrenia patients. METHOD: We conducted a prospective randomized controlled trial in which we enrolled patients defined by appropriate Structured Clinical Interview for DSM-IV diagnosis and < or = 16 weeks of lifetime antipsychotic exposure. Participants were randomly assigned (2:1 ratio) to a recommendation of changing to RLAI versus continuing on oral therapy (ORAL). Nonadherence behavior was defined as a medication gap > or = 14 days. Adherence attitudes were determined by the Rating of Medication Influences (ROMI) scale. A priori analysis defined treatment groups as intent-to-treat (ITT) and as-actually-treated (AAT) for the first 12 weeks after initial randomization. Participants were enrolled from December 2004 to March 2007. RESULTS: Of 46 eligible patients, 37 were randomly assigned, 11 to ORAL and 26 to RLAI. Nineteen of 26 patients (73%) accepted the RLAI recommendation. There were no differences in adherence behavior at 12 weeks based on initial randomization (Kaplan-Meier survival for ITT: 76% [95% CI, 35%-90%] adherent for RLAI vs 72% [95% CI, 55%-89%] for ORAL; log-rank P = .78), but patients accepting RLAI were significantly more likely to be adherent than patients staying on ORAL (AAT: 89% [95% CI, 64%-97%] adherent for RLAI vs 59% [95% CI, 32%-78%] for ORAL; log-rank P = .035). There were no ROMI attitude differences between either treatment group comparison at 12 weeks. CONCLUSIONS: Most first-episode patients taking oral antipsychotics will accept a recommendation of RLAI therapy. On the basis of initial randomization status, an RLAI recommendation did not affect adherence behavior at 12 weeks. However, acceptance of RLAI was associated with significantly better adherence. Regardless of whether RLAI is recommended or accepted, there is no adverse impact on subsequent medication attitudes at 12 weeks. These results support the feasibility and acceptability of introducing RLAI as a treatment option for first-episode schizophrenia patients. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00220714.

Lessening Homelessness Among Persons with Mental Illness: A Comparison of Five Randomized Treatment Trials.

We evaluate the influence of housing, services, and individual characteristics on housing loss among formerly homeless mentally ill persons who participated in a five-site (4-city) study in the U.S. Housing and service availability were manipulated within randomized experimental designs and substance abuse and other covariates were measured with a common protocol. Findings indicate that housing availability was the primary predictor of subsequent ability to avoid homelessness, while enhanced services reduced the risk of homelessness if housing was also available. Substance abuse increased the risk of housing loss in some conditions in some projects, but specific findings differed between projects and with respect to time spent in shelters and on the streets. We identify implications for research on homeless persons with mental illness that spans different national and local contexts and involves diverse ethnic groups.

Fundamental Causes of Housing Loss among Persons Diagnosed with Serious and Persistent Mental Illness: A Theoretically Guided Test.

Previous research on housing loss among severely mentally ill persons who have been placed in housing after being homeless has been largely atheoretical and has yielded inconsistent results. We develop a theory of housing loss based on identifying fundamental causes-problems in motives, means and social situation-and test these influences in a longitudinal, randomized comparison of housing alternatives. As hypothesized, individuals were more likely to lose housing if they had a history of alcohol or drug abuse, desired strongly to live independently contrary to clinician recommendations, or were African Americans placed in independent housing. Deficits in daily functioning did not explain these influences, but contributed to risk of housing loss. Our results demonstrate the importance of substance abuse, the value of distinguishing support preferences from support needs, and the necessity of explaining effects of race within a social context and thus should help to improve comparative research.

The role of neurocognition and social context in predicting community functioning among formerly homeless seriously mentally ill persons.

OBJECTIVE: To test the influence of neurocognitive functioning on community functioning among formerly homeless persons with serious mental illness and to determine whether that influence varies with social context, independent of individual characteristics. METHODS: In metropolitan Boston, 112 persons in Department of Mental Health shelters were administered a neuropsychological test battery and other measures and then randomly assigned to empowerment-oriented group homes or independent apartments, as part of a longitudinal study of the effects of housing on multiple outcomes. Subjects' case managers completed Rosen's 5-dimensional Life Skills Inventory at 3, 6, 12, and 18 months and subjects reported on their social contacts at baseline, 6, 12, and 18 months. Subject characteristics are controlled in the analysis. RESULTS: Three dimensions of neurocognitive functioning--executive function, verbal declarative memory, and vigilance--each predicted community functioning. Better executive function predicted improved self-care and less turbulent behavior among persons living alone, better memory predicted more positive social contacts for those living in a group home, and higher levels of vigilance predicted improved communication in both housing types. CONCLUSION: Neurocognition predicts community functioning among homeless persons with severe mental illness, but in a way that varies with the social context in which community functioning occurs.

Change in neurocognition by housing type and substance abuse among formerly homeless seriously mentally ill persons.

OBJECTIVE: To test the effect of living in group housing rather than independent apartments on executive functioning, verbal memory and sustained attention among formerly homeless persons with serious mental illness and to determine whether substance abuse modifies this effect. METHOD: In metropolitan Boston, 112 persons in Department of Mental Health shelters were randomly assigned to group homes ("Evolving Consumer Households", with project facilitator, group meetings, resident decision-making) or independent apartments. All were case managed. A neuropsychological test battery was administered at baseline, at 18 months (Time 2), with an 81% follow-up rate, and at 48 months (Time 3), with a 59% follow-up rate. Hierarchical Linear Modeling was applied to executive functioning--assessed with the Wisconsin Card Sorting Test (Perseverations)-Logical Memory story recall, and an auditory Continuous Performance Test (CPT) for sustained attention. Subject characteristics were controlled. RESULTS: When moved to group homes, subjects without a lifetime substance abuse history improved on Perseverations, while those who moved to independent apartments deteriorated on Perseverations. Across the two housing conditions, subjects showed no change in Perseverations, but improved on Logical Memory story recall and the CPT. CONCLUSIONS: Type of housing placement can influence cognitive functioning; notably, socially isolating housing is associated with weakened executive functioning. Substance abuse significantly diminishes environmental effects. These are important factors to consider in housing placement and subsequent treatment.

The effect of housing interventions on neuropsychological functioning among homeless persons with mental illness.

The authors tested the hypotheses that neuropsychological functioning would improve after homeless persons with severe and persistent mental illness were provided with housing and that executive functioning would improve more among those placed in group homes than among those placed in independent apartments. A total of 114 persons with serious and persistent mental illness who were stable residents of homeless shelters completed neuropsychological testing and were randomly assigned to group homes or independent apartments; 91 participants (52 assigned to group homes and 39 assigned to independent apartments) were retested after 18 months. Overall neuropsychological functioning improved significantly across the full study sample. Executive performance, measured by the Wisconsin Card Sorting Test, decreased significantly among persons assigned to independent apartments and increased, but not significantly, among those assigned to group homes. The findings suggest that providing housing for persons who have severe and persistent mental illness improves cognitive functioning but that independent living may diminish executive functioning.