Clinical decision support systems in state hospitals.

Computerized data management technology for clinical decision making is a key to optimizing the performance of programs serving the most severely disabled and treatment-resistant patients.

State hospitals in the twenty-first century: a formulation.

Readers are invited to evaluate the degree to which ideologies are influencing mental health planning and policy development activities in their own system.

Accuracy of the seven subtest WAIS-R short form in chronic schizophrenia.

The accuracy of the WAIS-R seven subtest short form (Ward, L.C., 1990. Prediction of Verbal, Performance and Full Scale IQs from seven subtests of the WAIS-R. J. Clin. Psychol. 46, 436-440) was examined for predicting IQs of 73 inpatients diagnosed with schizophrenia. Results indicated that 93% of the estimated Full Scale IQs were within +/-5 points of their actual scores. Using Wechsler's (1981) seven category intelligence classification, the level of agreement on the Full Scale IQ was 84% for the standard WAIS-R and the seven subtest short form. This abbreviated Wechsler Scale may be used with schizophrenic patients when only general estimates of intellectual functioning are required.

Cognitive functioning in schizophrenia: implications for psychiatric rehabilitation.

Research in psychopathology and the cognitive neurosciences suggests new applications in psychiatric rehabilitation. Analysis of performance deficits on laboratory tasks can contribute to treatment planning, individual and family counseling, and staff consultation, much like it does in cases of brain injury and other types of central nervous system neuropathology. Recognition of the nature of cognitive impairments in schizophrenia can inform design of psychosocial techniques such as social and living skills training. Cognitive impairments are increasingly seen as potential targets for pharmacological and psychosocial treatment and rehabilitation. In this article, three key issues for application of cognitive technology in psychiatric rehabilitation of schizophrenia and related disorders are formulated as straightforward, clinically relevant questions: (1) What is the prognostic significance of cognitive impairment in acute psychosis? (2) Can cognitive functioning improve in the chronic, residual course? (3) How does cognitive improvement benefit other aspects of recovery and rehabilitation? These questions are addressed through review of previous findings and new multivariate analyses of cognitive functioning in the acute, post-acute, and chronic residual phases of schizophrenia.

Effects of cognitive treatment in psychiatric rehabilitation.

Ninety subjects with severe and disabling psychiatric conditions, predominantly schizophrenia, participated in a controlled-outcome trial of the cognitive component of Integrated Psychological Therapy (IPT), a group-therapy modality intended to reestablish basic neurocognitive functions. The cognitive therapy was delivered to subjects in the experimental condition during intensive 6-month treatment periods. Control subjects received supportive group therapy. Before, during, and after the intensive treatment period, all subjects received an enriched regimen of comprehensive psychiatric rehabilitation, including social and living skills training, optimal pharmacotherapy, occupational therapy, and milieu-based behavioral treatment. IPT subjects showed incrementally greater gains compared with controls on the primary outcome measure, the Assessment of Interpersonal Problem-Solving Skills, suggesting that procedures that target cognitive impairments of schizophrenia spectrum disorders can enhance patients' response to standard psychiatric rehabilitation, at least in the short term, in the domain of social competence. There was equivocal evidence for greater improvement in the experimental condition on the Brief Psychiatric Rating Scale disorganization factor and strong evidence for greater improvement on a laboratory measure of attentional processing. There was significant improvement in both conditions on measures of attention, memory, and executive functioning, providing support for the hypothesis that therapeutic procedures that target impaired cognition enhance response to conventional psychiatric rehabilitation modalities over a 6-month timeframe.

Cognitive models in a fuller understanding of schizophrenia.

There is a gap in scientific understanding of psychiatric disorders such as schizophrenia, between neurophysiological models of etiology and the behavioral expressions of the disorders. More complete cognitive models are needed to fill that gap. Such models would set neurophysiological models in a more meaningful context, would show how biological processes produce social-behavioral impairments, and would inform both biological and psychosocial treatment strategies. To be fully functional, however, cognitive models must address two key principles: diathesis-stress in the course of schizophrenia, and the nature of reciprocal causality in complex, self-regulating biosystems.

Cognition and causality, fiction and explanation.

The debate about the causal efficacy of cognition involves two overlapping but different issues: (1) whether explanatory fictions improve upon the power and utility of nonfictional explanations of behavior, and (2) whether any explanation, either purely empirical or purely inferential, can describe proximal causality in behavioral functioning. The resolution of the first issue depends on the purpose to which the explanation is to be put. The resolution of the second issue depends on the larger paradigmatic context in which causality is understood. In modern biosystemic models of behavior, linear causality is important only as a special case of the multidirectional and reciprocal causality which characterizes complex self-regulating systems.

Dispelling the stigma of schizophrenia: what sort of information is best?

This study investigated what type of information reduces stigmatization of schizophrenia. Subjects were presented with one of six varying descriptions of a hypothetical case in which a target individual had recovered from a mental disorder. Subjects were asked if they knew someone with a mental illness. Those individuals who had no previous contact perceived the mentally ill as dangerous and chose to maintain a greater social distance from them. In general, knowledge of the symptoms associated with the acute phase of schizophrenia created more stigma than the label of schizophrenia alone. In contrast, more information about the target individuals post-treatment living arrangements (i.e., supervised care) reduced negative judgments. Implications for public education and future research are discussed.

Changing cognitive functioning in rehabilitation of schizophrenia.

A three-factor model is proposed for clinical assessment of cognitive and neuropsychological impairments in schizophrenia. The first factor is stable, pervasive and vulnerability-linked. The second and third include executive, memory and conceptual abilities and are episode-linked. The third factor may be amendable to psychosocial treatment.

Information processing and social cognitive problem solving in schizophrenia. Assessment of interrelationships and changes over time.

The relationship between basic information processing and social cognitive problem solving (SCPS) was studied in 31 schizophrenic, 16 depressive, and 31 control subjects. The clinical subjects were assessed twice, during symptom exacerbation and 3 months later, after partial remission. Control subjects were tested during the same time period. Subjects completed a means-ends problem-solving test, an alternative solution generation task, and an information-processing test battery. Results showed that schizophrenic subjects demonstrated significant improvement in a number of information-processing indices over time. No significant changes on the social cognitive problem-solving variables were found. Furthermore, all three groups demonstrated different patterns of relationships between information processing and social cognitive problem solving. Implications for treatment are discussed.

Design prerequisites for research on cognitive therapy for schizophrenia.

The results of various case studies, experiments, and quasi-experimental studies of cognitively oriented treatment interventions for schizophrenia are grounds for optimism. However, there are important methodological pitfalls that must be addressed if large-scale research is to confirm the efficacy of the cognitive approach. The pitfalls involve the heterogeneity of schizophrenia and its cognitive impairments, and the role of specific and nonspecific factors in psychosocial treatments. Special methodological and design strategies are required to address these complications.

University-state hospital collaboration in an inpatient psychiatric rehabilitation program.

From 1981 until present the Department of Psychology of the University of Nebraska-Lincoln has collaborated with the Lincoln Regional Center, a state hospital, on an inpatient psychiatric rehabilitation project. The University provides clinical psychology services under contract, including direct clinical services and consultation on program development. The project includes a 40-bed inpatient treatment unit, which represents a clinical training and research site for University faculty and graduate students. Program evaluation data indicate the collaboration has produced a cost-effective state-of-the-art treatment program, now considered a model for psychiatric rehabilitation services across the state. The collaboration played a key role in securing two major grants, one for specialty training for clinical psychologists in schizophrenia and psychiatric rehabilitation, one for a treatment outcome study. Facilitating factors in the project include convergence of the collaborators' professional and research interests with national and state mental health policy. Obstacles include hospital administrative policies which fail to recognize or appreciate requirements for program management and accountability, and unwillingness to recognize program leadership from nonmedical professionals.

Training psychologists for work with the chronically mentally ill.

While clinical psychologists have made a strong contribution to research and service delivery to the chronically mentally ill, the profession still experiences a shortage of human resources for work in this area. The roles and functions of clinical psychologists are specified and the prevalent model of training is described in light of the needs for services to CMI.

Applications of experimental psychopathology in psychiatric rehabilitation.

Persons with schizophrenia show deficits in basic psychological functions such as attention, perception, and cognition. Remediation of these deficits by direct training may facilitate the effectiveness of neuroleptic medications, social skills training, and family therapy. In the vulnerability-stress model of schizophrenia, persons with schizophrenia may have lower thresholds for disorganization that contribute to vulnerability. Stress increases arousal, which brings many competing responses to the same strength, leading to intrusion of inappropriate responses. Interventions that reduce arousal and lower the strengths of competing responses should reduce psychological deficits. Arousal-reducing, attentional, and cognitive interventions are appropriate for the prodromal, acute, and chronic stages of schizophrenic disorders. Laboratory-based assessment and ongoing measurement of basic psychological deficits in schizophrenia are keys to the development and validation of multimodal psychiatric rehabilitation.