Cost-effectiveness of cognitive remediation and supported employment for people with mental illness: a randomized controlled trial.

BACKGROUND: Little is known about the economic benefits of cognitive remediation and supported employment (CR + SE). The present study aimed to investigate the cost-effectiveness of CR + SE compared with traditional vocational services (TVS). METHOD: Individuals with mental illness and low cognitive function were recruited at six sites in Japan. A total of 111 participants were randomly allocated to the CR + SE group or the TVS group. Clinical and vocational outcomes were assessed at baseline and 12-month follow-up. Service utilization data were collected monthly. The data on outcomes and costs were combined to examine cost-effectiveness. RESULTS: The data were obtained from a total of 92 participants. The CR + SE group resulted in better vocational and clinical outcomes (employment rate, 62.2%; work tenures, 78.6 days; cognitive improvement, 0.5) than the TVS group (19.1%, 24.9 days and 0.2). There was no significant difference in mean total costs between the groups (CR + SE group: $9823, s.d. = $6372, TVS group: $11 063, s.d. = $11 263) with and without adjustment for covariates. However, mean cost for medical services in the CR + SE group was significantly lower than that in the TVS group after adjusting covariates (Β = -$3979, 95% confidence interval -$7816 to -$143, p = 0.042). Cost-effectiveness acceptability curves for vocational outcomes illustrated the high probabilities (approximately 70%) of the CR + SE group being more cost-effective than TVS when society is not willing to pay additional costs. CONCLUSIONS: CR + SE appears to be a cost-effective option for people with mental illness who have low cognitive functioning when compared with TVS.

Psychophysiological correlates of social skills deficits in persons with schizophrenia.

Social skill deficits in schizophrenia profoundly affect patients' life-long outcome, although the profile of the underlying cognitive dysfunction still remains a matter of debate. In the present study, we investigated the relationship between social skills and event-related potentials (ERPs) in an auditory selective attention task, in addition to the neurocognitive indices obtained from the degraded-stimulus continuous performance test (CPT) and clinical indices, such as Brief Psychiatric Rating Scale (BRPS) and global assessment of function (GAF) scores. Social skills were assessed using a Japanese version of the structured role play test. Fourteen persons with schizophrenia participated in the study. Non-verbal skills showed a positive correlation with GAF, the performance level, N1 and N2b amplitude in the ERP task, and hit rate in the CPT, and a negative correlation with reaction time in the CPT. Verbal communication skills showed a positive correlation with GAF, the performance level and N2b amplitude in the ERP task, and hit rate in the CPT, and a negative correlation with reaction time in the CPT. Processing skills showed a positive correlation with the performance level and N1 amplitude in the ERP task and a negative correlation with reaction time in the CPT. These findings suggested that the social skill deficits of persons with schizophrenia were related to the vigilance level and controlled stimulus detection processing.

Comparison of the effects of zolpidem and zopiclone on nocturnal sleep and sleep latency in the morning: a cross-over study in healthy young volunteers.

Zolpidem (ZOL) and zopiclone (ZPC) are non-benzodiazepine hypnotics, with unique effects on sleep architecture compared with conventional benzodiazepines. The two compounds have different profiles in action to two major subtypes of the GABA-A receptors, therefore different effects on sleep structure may be expected. In the present study, the effects of ZOL (10mg) and ZPC (7.5mg) were compared in nine healthy young male subjects during nine-night sessions, employing a crossover design. Time courses during the sessions were significantly different between the compounds in the ratio (%) of S2 and S1. Compared to the baseline, an increase of S2 and a decrease of S1 and SR were caused by ZPC, not by ZOL. SWS was increased by both ZPC and ZOL. Significant changes by ZOL were found during the first 150-min, while changes by ZPC were mostly observed during the second 150-min. This might be related to their half-lives. ZOL did not affect sleep latency in the morning, while ZPC caused a significant decrease. Subjective sleepiness, however, was not increased in the ZPC or ZOL mornings. It was speculated that difference in the action to the GABA-A receptor subtypes might be related to the differences in the effects on the sleep architecture between the compounds.

How do early stages of information processing influence social skills in patients with schizophrenia?

Persons with schizophrenia show deficits across a broad range of cognitive domains, and their social skill deficits are thought, to some extent, to be caused by cognitive dysfunction. In this study, we attempted to replicate the correlation between the early stages of information processing and non-verbal skills. Subjects for the study included 22 men and six women who met DSM-IV criteria for the diagnosis of schizophrenia. All subjects were attending a rehabilitation program at the day-treatment centers of their hospitals. Social skills were assessed using a structured role-play test. The Degraded-Continuous Performance Test (CPT) and Span of Apprehension Test (SPAN) were used. Non-verbal skills were significantly correlated with CPT-False Alarm Rate (the rate of commission errors of all trials) in multiple regression analysis, but the receiving-processing skills did not have any relation to CPT or SPAN score. Non-verbal skills may be related to early information-processing deficiency, especially the response-inhibiting system. Receiving and processing skills may be related to later stages of information processing, or may reflect not only 'molecular' stages of information processing (less complex and less integration task in a continuum of complexity of cognitive processes) but also other factors such as social learning.

What influences social skills in patients with schizophrenia? Preliminary study using the role play test, WAIS-R and event-related potential.

Persons with schizophrenia exhibit disabilities which profoundly affect their social and independent living skills, and social skills training is expected to be an effective treatment for reducing the level of severity of disabilities. Many factors may influence usage and learning of social skills; little is definitively known regarding which disabilities related to schizophrenia compromise social skills. The present report deals with factors affecting social skills. Twenty persons with schizophrenia (DSM-III-R) were tested using a Japanese version of the role play test, the reliability and validity of which were verified. Subjects were also tested using BPRS, auditory event-related potential (ERP) and WAIS-R. Nonverbal skills showed significant positive correlation with the amplitude of the N1 ERP component and age of onset, and 59% of the variance of nonverbal skills was accounted for by these factors using multiple regression analysis. Nonverbal skills are at least partially based on either automatic discriminating processes or selective attention, reflected in N1A. Information receiving and processing skills showed significant positive correlation with Performance IQ and Global Assessment of Functioning, and 61% of the variance of receiving and processing skills was accounted for by BPRS score, PIQ score and age. These skills are not directly related to elementary cognitive function as assessed by analyzing, for example, the ERP P3 component, but are based on more complex neuropsychological function.

Effect of the medication management module evaluated using the role play test.

Training in social skills has been shown to have a strong, positive impact, according to behavioral measures, on social skills, self-rated assertiveness, and the hospital discharge rate. It is important to establish a system of assessing social skills because it is necessary for the effects of social skills training to be assessed in Japan. In Project 1, we devised a Japanese version of the role play test to quantify social skills using a standard method. We tested 30 patients attending the day hospital who were considered to need intensive rehabilitation. We found the role play test had high inter-rater and test-retest reliability, and had construct validity and criterion related validity. Thus, the role play test was thought to be a useful tool for assessing social skills. For Project 2, eight inpatients who were ready for discharge but who needed to improve their skills in self-managed medication participated in this study. The social skills of self-managed medication assessed using the role play test were significantly improved after the subjects participated in the Medication Management Module of the UCLA social and independent living skills program. Knowledge of self-managed medication also tended to improve after training. This study is preliminary and it should be confirmed that improved skills influenced by the medication management module decreases the relapse rates.

[Assessment of social disability of patients suffering from chronic mental illness with the role play test].

UNLABELLED: Among the chronic mentally ill patients, disabilities invade most parts of their social functioning, and influences their long term course profoundly. It is important clinical issue to improve disability. Social skills training is assumed to be effective method to improve disability, and it has been disseminated over Japan recently. The assessment system to evaluate disabilities objectively at the viewpoint of social skills must be required to verify effects of social skills training, and to develop further effective therapeutic method. A role play test is the assessment tool for social skills through role plays under specific social conditions. It was reported to be useful as the method of functional assessment before treatment, and as the tool to evaluate effects of treatment to improve disability. PURPOSE: We created the Role Play Test (RPT) which was adapted to Japanese cultural background, and we tried to verify feasibility, reliability, and validity of the RPT. SUBJECTS: Thirty out-patients attending in the Day Hospital attached to Tokyo University Hospital. Twenty-six were schizophrenia, and 4 were other diagnoses. METHOD: Subjects were assessed with the RPT, BPRS, SANS, four rating scales for social functioning, and self-efficacy rating scale. The RPT was designed to assess components of social skills--social perception, role play behavior, and self-efficacy. Role play behaviors were recorded with video tapes for analysis of interrater reliability. The RPT is consisted of 12 scenes to evaluate social skills which are required in daily life. Statistical analyses were done with SAS (Statistical Analysis System). RESULTS: (1) The RPT was presumed to be feasible clinically, because the RPT could be practiced easily and responsibilities of both subjects and testers were not so much. (2) Interrater reliabilities assessed with ANOVA-ICC on 12 items was sufficiently high except one item. (3) Construct validity was certified through factor analysis, and criterion-related validity was certified through correlation analysis with other rating scales of social functioning. (4) Individual profile of the RPT should be useful instrument for functional analysis before social skills training. We also discussed on some hypotheses on the causal relationship between positive and negative symptoms and social skills. The RPT could be used as a tool to research causes of disabilities, and to evaluate improvement of social functioning after psycho-social intervention including social skills training, because the RPT can assess social skills quantitatively according to the cognitive-behavioral model.

Frequency of criteria-defined borderline patients among the first-visit patients at a psychiatric clinic.

Five trained psychiatrists evaluated 330 first-visit patients aged from 12 to 30 at a psychiatric outpatient facility using the DSM-III criteria (Axis-I and Axis-II). Seven cases were diagnosed as definite Borderline Personality Disorder and six cases as definite Schizotypal Personality Disorder. Hence, we had a total of 13 criteria-defined borderline patients (3.9%). Discussions were held on some methodological problems involved in collecting information and making diagnostic judgments.