Enhancing patient-clinician collaboration during treatment decision-making: study protocol for a community-engaged, mixed method hybrid type 1 trial of collaborative decision skills training (CDST) for veterans with psychosis.

BACKGROUND: Patient participation in treatment decision making is a pillar of recovery-oriented care and is associated with improvements in empowerment and well-being. Although demand for increased involvement in treatment decision-making is high among veterans with serious mental illness, rates of involvement are low. Collaborative decision skills training (CDST) is a recovery-oriented, skills-based intervention designed to support meaningful patient participation in treatment decision making. An open trial among veterans with psychosis supported CDST's feasibility and demonstrated preliminary indications of effectiveness. A randomized control trial (RCT) is needed to test CDST's effectiveness in comparison with an active control and further evaluate implementation feasibility. METHODS: The planned RCT is a hybrid type 1 trial, which will use mixed methods to systematically evaluate the effectiveness and implementation feasibility of CDST among veterans participating in a VA Psychosocial Rehabilitation and Recovery Center (PRRC) in Southern California. The first aim is to assess the effectiveness of CDST in comparison with the active control via the primary outcome, collaborative decision-making behavior during usual care appointments between veterans and their VA mental health clinicians, and secondary outcomes (i.e., treatment engagement, satisfaction, and outcome). The second aim is to characterize the implementation feasibility of CDST within the VA PRRC using the Practical Robust Implementation and Sustainability Model framework, including barriers and facilitators within the PRRC context to support future implementation. DISCUSSION: If CDST is found to be effective and feasible, implementation determinants gathered throughout the study can be used to ensure sustained and successful implementation at this PRRC and other PRRCs and similar settings nationally. TRIAL REGISTRATION: ClinicalTrials.gov NCT04324944. Registered on March 27, 2020. Trial registration data can be found in Appendix 1.

Pilot feasibility trial of a brief mobile-augmented suicide prevention intervention for serious mental illness.

OBJECTIVE: People with serious mental illnesses (SMIs) are at high risk for suicidal ideation and behavior, and yet few suicide prevention interventions have been customized for this group. We describe the outcomes of a pilot trial of Mobile SafeTy And Recovery Therapy (mSTART), a four-session suicide-focused cognitive behavioral intervention for SMI, designed for the transition from acute to outpatient care and augmented with ecological momentary intervention to reinforce intervention content. METHODS: The primary objective of this pilot trial was to evaluate the feasibility, acceptability, and preliminary effectiveness of START. Seventy-eight people with SMI and elevated suicidal ideation were randomized to either: (a) mSTART or (b) START alone (i.e., without mobile augmentation). Participants were evaluated at baseline, 4 weeks (end of in-person sessions), 12 weeks (end of mobile intervention), and 24 weeks. The primary outcome of the study was change in suicidal ideation severity. Secondary outcomes included psychiatric symptoms, coping self-efficacy, and hopelessness. RESULTS: A total of 27% of randomized persons were lost to follow-up after baseline, and engagement with mobile augmentation was variable. There was clinically significant improvement (d = 0.86) in suicidal ideation severity scores sustained over 24 weeks, with similar effects seen for secondary outcomes. Preliminary comparison indicated a medium effect size (d = 0.48) advantage at 24 weeks of mobile augmentation in suicidal ideation severity scores. Treatment credibility and satisfaction scores were high. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: START, regardless of mobile augmentation, was associated with sustained improvement in suicidal ideation severity and secondary outcomes in people with SMI at-risk for suicide in this pilot trial. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Using a stakeholder-engaged, iterative, and systematic approach to adapting collaborative decision skills training for implementation in VA psychosocial rehabilitation and recovery centers.

BACKGROUND: Adaptation of interventions is inevitable during translation to new populations or settings. Systematic approach to adaptation can ensure that fidelity to core functions of the intervention are preserved while optimizing implementation feasibility and effectiveness for the local context. In this study, we used an iterative, mixed methods, and stakeholder-engaged process to systematically adapt Collaborative Decision Skills Training for Veterans with psychosis currently participating in VA Psychosocial Rehabilitation and Recovery Centers. METHODS: A modified approach to Intervention Mapping (IM-Adapt) guided the adaptation process. An Adaptation Resource Team of five Veterans, two VA clinicians, and four researchers was formed. The Adaptation Resource Team engaged in an iterative process of identifying and completing adaptations including individual qualitative interviews, group meetings, and post-meeting surveys. Qualitative interviews were analyzed using rapid matrix analysis. We used the modified, RE-AIM enriched expanded Framework for Reporting Adaptations and Modifications to Evidence-based interventions (FRAME) to document adaptations. Additional constructs included adaptation size and scope; implementation of planned adaptation (yes-no); rationale for non-implementation; and tailoring of adaptation for a specific population (e.g., Veterans). RESULTS: Rapid matrix analysis of individual qualitative interviews resulted in 510 qualitative codes. Veterans and clinicians reported that the intervention was a generally good fit for VA Psychosocial Rehabilitation and Recovery Centers and for Veterans. Following group meetings to reach adaptation consensus, 158 adaptations were completed. Most commonly, adaptations added or extended a component; were small in size and scope; intended to improve the effectiveness of the intervention, and based on experience as a patient or working with patients. Few adaptations were targeted towards a specific group, including Veterans. Veteran and clinician stakeholders reported that these adaptations were important and would benefit Veterans, and that they felt heard and understood during the adaptation process. CONCLUSIONS: A stakeholder-engaged, iterative, and mixed methods approach was successful for adapting Collaborative Decision Skills Training for immediate clinical application to Veterans in a psychosocial rehabilitation center. The ongoing interactions among multiple stakeholders resulted in high quality, tailored adaptations which are likely to be generalizable to other populations or settings. We recommend the use of this stakeholder-engaged, iterative approach to guide adaptations.

Integrated Cognitive-Behavioral Social Skills Training and Compensatory Cognitive Training for Negative Symptoms of Psychosis: Effects in a Pilot Randomized Controlled Trial.

OBJECTIVE: Negative symptoms and cognitive impairment in schizophrenia (SZ) remain unmet treatment needs as they are highly prevalent, associated with poor functional outcomes, and resistant to pharmacologic treatment. The current pilot randomized controlled trial examined the efficacy of an integrated Cognitive-Behavioral Social Skills Training and Compensatory Cognitive Training (CBSST-CCT) intervention compared to Goal-focused Supportive Contact (SC) on negative symptoms and cognitive performance. METHODS: Fifty-five adults with SZ or schizoaffective disorder with moderate-to-severe negative symptoms were randomized to receive 25 twice-weekly, 1-h manualized group sessions (12.5 weeks total duration) of either CBSST-CCT or SC delivered by master's level clinicians in five community settings. Assessments of negative symptom severity (primary outcomes) and neuropsychological performance, functional capacity, social skills performance, and self-reported functional ability/everyday functioning, psychiatric symptom severity, and motivation (secondary outcomes) were administered at baseline, mid-treatment, post-treatment, and 6-month follow-up. RESULTS: Mixed-effects models using baseline, mid-treatment, and post-treatment data demonstrated significant CBSST-CCT-associated effects on negative symptom severity, as assessed by the Scale for the Assessment of Negative Symptoms (p = .049, r = 0.22), with improvements in diminished motivation driving this effect (p = .037, r = 0.24). The CBSST-CCT group also demonstrated improved verbal learning compared to SC participants (p = .026, r = 0.36). The effects of CBSST-CCT appeared to be durable at 6-month follow-up. CONCLUSIONS: CBSST-CCT improved negative symptom severity and verbal learning in high-negative-symptom individuals relative to SC. CBSST-CCT warrants larger investigations to examine its efficacy in treating negative symptoms, along with other symptoms, cognition, and, ultimately, real-world functional outcomes. Clinical Trial registration number NCT02170051.

Designed and created for a veteran by a veteran: A pilot study of caring cards for suicide prevention.

INTRODUCTION: This pilot study investigates feasibility and acceptability of Caring Cards, a suicide prevention intervention inspired by Caring Contacts and the Recovery Model, where Veteran peers create cards that are sent to Veterans recently discharged from a VA psychiatric hospitalization for suicide risk. METHODS: Caring Cards consists of: (1) a weekly outpatient group where Veterans (card makers) create cards, and (2) sending cards to recently discharged Veterans (card recipients). Feasibility for card makers was measured by attendance; acceptability (satisfaction) was examined. Card recipients were sent one caring card, one week post-discharge. Feasibility for recipients was measured by the percentage of Veterans that met eligibility and follow-up response rate; acceptability (satisfaction) was examined. RESULTS: Caring Cards is feasible and acceptable. The outpatient group had a higher attendance rate (81%) compared with other clinic groups. The percentage of eligible card recipients was 61%. Of these, 69% were reached for follow-up and 50% provided follow-up responses. Card makers and recipients both expressed positive experiences with Caring Cards. CONCLUSION: Caring Cards is a low-intensity, feasible, and acceptable intervention with potential benefits for both Veteran card makers and recipients. Additional research is needed to determine the efficacy of Caring Cards as a suicide prevention intervention.

A Brief Mobile-Augmented Suicide Prevention Intervention for People With Psychotic Disorders in Transition From Acute to Ongoing Care: Protocol for a Pilot Trial.

BACKGROUND: People with serious mental illnesses (SMIs) are at exceptionally high risk for lifetime suicidal ideation and behavior compared with the general population. The transition period between urgent evaluation and ongoing care could provide an important setting for brief suicide-specific interventions for SMIs. To address this concern, this trial, SafeTy and Recovery Therapy (START), involves a brief suicide-specific cognitive behavioral intervention for SMIs that is augmented with mobile phone interactions. OBJECTIVE: The primary aim of this pilot trial is to evaluate the feasibility, acceptability, and preliminary effectiveness of the intervention. METHODS: A 6-month pilot trial with 70 participants with a diagnosis of bipolar disorder, schizophrenia or schizoaffective disorder, and current active suicidal ideation were randomized to START or START with mobile augmentation. START consists of 4 weekly sessions addressing early warning signs and triggers, symptoms influencing suicidal thinking, and social relationships. Recovery planning is followed by biweekly telephone coaching. START with mobile augmentation includes personalized automated cognitive behavioral therapy scripts that build from in-person content. Participants were evaluated at baseline, 4 weeks (end of in-person sessions), 12 weeks (end of telephone coaching), and 24 weeks. In addition to providing point estimates of feasibility and acceptability, the primary outcome of the trial was the change in severity of suicidal ideation as measured with the Scale for Suicide Ideation (SSI) and secondary outcome included the rate of outpatient engagement. RESULTS: The trial is ongoing. Feasibility and acceptability across conditions will be assessed using t tests or Mann-Whitney tests or chi-square tests. The reduction of SSI over time will be assessed using hierarchical linear models. CONCLUSIONS: The design considerations and results of this trial may be informative for adapted suicide prevention in psychotic disorders in applied community settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT03198364; http://clinicaltrials.gov/ct2/show/NCT03198364. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/14378.

Reducing negative symptoms in schizophrenia: Feasibility and acceptability of a combined cognitive-behavioral social skills training and compensatory cognitive training intervention.

The current study examined the feasibility and acceptability of an integrated Cognitive-Behavioral Social Skills Training and Compensatory Cognitive Training (CBSST-CCT) intervention compared with Goal-Focused Supportive Contact (SC) in a pilot randomized controlled trial for people with schizophrenia with high negative symptom severity. The sample included 55 participants from five community settings; masters-level study clinicians delivered interventions on-site. Participants completed assessments of cognitive, functional, and psychiatric symptoms at baseline, mid-treatment, post-treatment (12.5 weeks), and 6-month follow-up. Enrollment goals were not initially met, necessitating the addition of a fifth site; however, all groups and assessments were completed on-site. Study procedures were acceptable, as evidenced by 100% enrollment and completion of baseline assessments following informed consent; however, over 1/3rd of participants dropped out. No modifications were necessary to the intervention procedures and CBSST-CCT fidelity ratings were acceptable. The intervention was deemed acceptable among participants who attended ≥1 session, as evidenced by similar attendance rates in CBSST-CCT compared to SC. Among CBSST-CCT participants, lower positive symptoms were significantly associated with better attendance. Overall, we found mixed evidence for the feasibility and acceptability of the CBSST-CCT protocol in people with schizophrenia with high negative symptoms. Challenges are highlighted and recommendations for future investigations are provided.

Single-Session Mobile-Augmented Intervention in Serious Mental Illness: A Three-Arm Randomized Controlled Trial.

Psychosocial interventions for serious mental illness are resource intensive and poorly accessible. Brief interventions (eg, single session) that are augmented by follow-on automated mobile health intervention may expand treatment access. This was a randomized single-blind controlled trial with 255 individuals diagnosed with schizophrenia or bipolar disorder. Participants were randomized to one of three conditions: CBT2go, which combined one individual session of cognitive behavioral therapy with automated thought challenging/adaptive behavior delivered through mobile devices; Self-Monitoring (SM), which combined single-session illness psychoeducation with self-monitoring of symptoms; and treatment-as-usual (TAU). Participants were assessed at baseline, 6 weeks (midpoint), 12 weeks (posttreatment), and 24 weeks (follow-up) with our primary outcome global psychopathology (Brief Psychiatric Rating Scale-expanded version [BPRS-24]), and secondary outcomes community functioning (Specific Level of Function; SLOF) and defeatist performance beliefs (DPBs). We also collected data on adverse events. Outcome analyses on the primary outcome, BPRS Total score, indicated a significant time (0-24 wk) by group interaction with significant but modest improvement comparing two active conditions (CBT2go and SM) relative to TAU. Effects of CBT2go were not different from SM. There was a significant time × group interaction with better SLOF scores in CBT2go across 24 weeks, but not in SM. There were no time-by-group effects on DPBs. DPBs decreased in the CBT2go condition but not in SM. These results indicated that single intervention augmented by mobile intervention was feasible and associated with small yet sustained effects on global psychopathology and, when inclusive of CBT, community function compared with usual care.

Stakeholder Perspectives on Implementing Cognitive Behavioral Social Skills Training on Assertive Community Treatment Teams.

This study examined stakeholder perceptions of the "fit" between cognitive-behavioral social skills training (CBSST) and assertive community treatment (ACT) when implementing CBSST into existing community-based ACT teams. Focus group feedback was collected from a diverse set of stakeholders (i.e., clients, providers, supervisors, agency administrators, public sector representatives, and intervention developers). Results identified perceived client and provider benefits for integrating CBSST into ACT while highlighting the importance of purposeful adaptations, training, and implementation tools to facilitate structural and values fit between CBSST and ACT. Study findings will inform future endeavors to implement CBSST and other relevant EBPs into ACT. Trial Registry: ClinicalTrials.gov #NCT02254733.

Technology to assess and support self-management in serious mental illness.

The functional impairment associated with serious mental illness (SMI) places an immense burden on individuals and society, and disability often persists even after efficacious treatment of psychopathologic symptoms. Traditional methods of measuring functioning have limitations, and numerous obstacles reduce the reach and impact of evidence-based interventions developed to improve functioning in SMI. This review describes the potential of technological innovations for overcoming the challenges involved in both functional assessment and intervention in people with SMI. Ecological momentary assessment (EMA), which involves the repeated sampling of naturalistic behaviors and experiences while individuals carry out their daily lives, has provided a new window through which the determinants of day-to-day function in SMI can be observed. EMA has several advantages over traditional assessment methods and has in recent years evolved to use mobile-based platforms, such as text messaging and smartphone applications, for both assessment and promotion of self-management in people with SMI. We will review promising data regarding the acceptability, adherence, and efficacy of EMA-based mobile technologies; explore ways in which these technologies can extend the reach and impact of evidence-based psychosocial rehabilitative interventions in SMI; and outline future directions for research in this important area.

El deterioro funcional asociado con la enfermedad mental grave (EMG) implica una inmensa carga para los individuos y la sociedad, y la discapacidad persiste aun después de tratamientos exitosos de los síntomas psicopatológicos. Los métodos tradicionales para medir funcionamiento tienen limitaciones y hay numerosos obstáculos que reducen el alcance e impacto de intervenciones basadas en la evidencia que se han desarrollado para mejorar el funcionamiento en las EMG. Esta revisión describe el potencial de las innovaciones tecnológicas para superar los desafíos involucrados tanto en la evaluación funcional como en las intervenciones en las EMG. La evaluación ecológica instantánea (EEI), que consiste en el muestreo repetido de conductas y experiencias naturalísticas mientras los sujetos desarrollan su vida diaria, ha aportado una nueva ventana a través de la cual se pueden observar los determinantes del funcionamiento día a día en las EMG. La EEI tiene algunas ventajas sobre los métodos de evaluación tradicional y ha evolucionado en los últimos años hacia el empleo de plataformas en base a móviles, como mensajes de texto y aplicaciones de teléfonos inteligentes, tanto para la evaluación como para la promoción del auto-manejo de personas con EMG. Se revisan datos prometedores en relación con la aceptabilidad, adherencia y eficacia de tecnologías móviles basadas en la EEI; se exploran vías en las que estas tecnologías pueden extender el alcance e impacto de las intervenciones de rehabilitación psicosocial basada en la evidencia en la EEI, y se describen las futuras direcciones de la investigación en esta importante área.

Le handicap fonctionnel lié aux maladies mentales graves impose un immense fardeau aux individus et à la société et l'invalidité persiste souvent même après un traitement efficace des symptômes psychopathologiques. Les méthodes traditionnelles de mesure du fonctionnement ont des limites et de nombreux obstacles diminuent la portée et l'incidence des interventions basées sur des preuves développées pour améliorer le fonctionnement des personnes atteintes de maladies mentales graves. Cet article explique comment les innovations technologiques peuvent permettre de surmonter les défis liés à l'évaluation et à l'intervention fonctionnelles chez les personnes atteintes de maladies mentales graves. L'évaluation écologique momentanée (EEM), qui comporte des échantillonnages répétés d'expérience et de comportements naturalistes, les individus continuant à vivre leur vie quotidienne, permet d'observer les déterminants du fonctionnement quotidien des personnes atteintes de maladies mentales graves. L'EEM présente plusieurs avantages sur les méthodes d'évaluation traditionnelles et a récemment évolué pour utiliser des platesformes mobiles, comme les SMS et les applications pour smartphone, pour l'évaluation et la promotion d'une gestion autonome des personnes atteintes de maladies mentales graves. Nous analyserons les données prometteuses concernant l'acceptabilité, l'observance et l'efficacité des technologies mobiles basées sur l'EEM; nous explorerons la façon dont ces technologies peuvent prolonger la portée et l'incidence des interventions de réhabilitation psychosocial basées sur des preuves des personnes atteintes de maladies mentales graves; et nous donnerons les grandes lignes des axes de recherche à venir dans ce domaine important.

Social behavior, interaction appraisals, and suicidal ideation in schizophrenia: The dangers of being alone.

Despite the increasing attention to social appraisals in suicide risk, the interpersonal correlates of suicidal thoughts and behavior in schizophrenia are not well understood. Ecological momentary assessment could reveal whether dysfunctional social appraisals and behavior are evident in people with schizophrenia with suicidal ideation. A total of 93 outpatients with diagnoses of schizophrenia with (n=18, 19%) and without (N=75; 81%) suicidal ideation participated in one week of intensive daily monitoring via mobile devices, generating real-time reports on the quantity of social interactions and appraisals about them, as well as information concerning concurrent affect and symptoms. The presence of suicidal ideation was not associated with the quantity of social interactions or time spent alone, but it was associated with the anticipation of being alone as well as greater negative and lower positive affect when alone. Despite this aversive experience of being alone, people with suicidal ideation reported negative appraisals about the value of recent and potential social interactions. These findings suggest that suicidal ideation in schizophrenia may not be associated with the quantity of social interactions, but with negative expectations about the quality of social interactions coupled with an aversive experience of being alone. Cognitive therapy interventions that address negative expectations and pleasure about social interactions, especially when alone, may reduce suicidal ideation.

Enhancing assertive community treatment with cognitive behavioral social skills training for schizophrenia: study protocol for a randomized controlled trial.

BACKGROUND: Schizophrenia leads to profound disability in everyday functioning (e.g., difficulty finding and maintaining employment, housing, and personal relationships). Medications can effectively reduce positive symptoms (e.g., hallucinations and delusions), but they do not meaningfully improve daily life functioning. Psychosocial evidence-based practices (EBPs) improve functioning, but these EBPs are not available to most people with schizophrenia. The field must close the research and service delivery gap by adapting EBPs for schizophrenia to facilitate widespread implementation in community settings. Our hybrid effectiveness and implementation study represents an initiative to bridge this divide. In this study we will test whether an existing EBP (i.e., Cognitive Behavioral Social Skills Training (CBSST)) modified to work in practice settings (i.e., Assertive Community Treatment (ACT) teams) commonly available to persons with schizophrenia results in better consumer outcomes. We will also identify key factors relevant to developing future CBSST implementation strategies. METHODS/DESIGN: For the effectiveness study component, persons with schizophrenia will be recruited from existing publicly funded ACT teams operating in community settings. Participants will be randomized to one of the 2 treatments (ACT alone or ACT + Adapted CBSST) and followed longitudinally for 18 months with assessments every 18 weeks after baseline (5 in total). The primary outcome domain is psychosocial functioning (e.g., everyday living skills and activities related to employment, education, and housing) as measured by self-report, testing, and observation. Additional outcome domains of interest include mediators of change in functioning, symptoms, and quality of services. Primary analyses will be conducted using linear mixed-effects models for continuous data. The implementation study component consists of a structured, mixed qualitative-quantitative methodology (i.e., Concept Mapping) to characterize and assess the implementation experience from multiple stakeholder perspectives in order to inform future implementation initiatives. DISCUSSION: Adapting CBSST to fit into the ACT service delivery context found throughout the United States creates an opportunity to substantially increase the number of persons with schizophrenia who could have access to and benefit from EBPs. As part of the implementation learning process training materials and treatment workbooks have been revised to promote easier use of CBSST in the context of brief community-based ACT visits. TRIAL REGISTRATION: ClinicalTrials.gov NCT02254733 . Date of registration: 25 April 2014.

Dysfunctional attitudes and expectancies in deficit syndrome schizophrenia.

The deficit syndrome was proposed over 20 years ago as a separate negative symptom syndrome within schizophrenia with a distinct neurobiological pathophysiology and etiology. Recent research, however, has indicated that psychological factors such as negative attitudes and expectancies are significantly associated with the broad spectrum of negative symptoms. Specifically, defeatist beliefs regarding performance mediate between neurocognitive impairment and both negative symptoms and functional outcome. Additionally, asocial beliefs predict asocial behavior and negative expectancies regarding future pleasure are associated with negative symptoms. The present study explored whether these dysfunctional beliefs and negative expectancies might also be a feature of the deficit syndrome. Based on a validated proxy method, 22 deficit and 72 nondeficit patients (from a pool of 139 negative symptom patients) were identified and received a battery of symptom, neurocognitive, and psychological measures. The deficit group scored significantly worse on measures of negative symptoms, insight, emotion recognition, defeatist attitudes, and asocial beliefs but better on measures of depression, anxiety, and distress than the nondeficit group. Moreover, the deficit group showed a trend for higher scores on self-esteem. Based on these findings, we propose a more comprehensive formulation of deficit schizophrenia, characterized by neurobiological factors and a cluster of psychological attributes that lead to withdrawal and protect the self-esteem. Although the patients have apparently opted-out of participation in normal activities, we suggest that a psychological intervention that targets these negative attitudes might improve their functioning and quality of life.

Randomized trial to evaluate the efficacy of cognitive therapy for low-functioning patients with schizophrenia.

CONTEXT: Low-functioning patients with chronic schizophrenia have high direct treatment costs and indirect costs incurred due to lost employment and productivity and have a low quality of life; antipsychotic medications and psychosocial interventions have shown limited efficacy to promote improved functional outcomes. OBJECTIVE: To determine the efficacy of an 18-month recovery-oriented cognitive therapy program to improve psychosocial functioning and negative symptoms (avolition-apathy, anhedonia-asociality) in low-functioning patients with schizophrenia. Design, Setting, and PARTICIPANTS: A single-center, 18-month, randomized, single-blind, parallel group trial enrolled 60 low-functioning, neurocognitively impaired patients with schizophrenia (mean age, 38.4 years; 33.3% female; 65.0% African American). INTERVENTIONS: Cognitive therapy plus standard treatment vs standard treatment alone. MAIN OUTCOME MEASURES: The primary outcome measure was the Global Assessment Scale score at 18 months after randomization. The secondary outcomes were scores on the Scale for the Assessment of Negative Symptoms and the Scale for the Assessment of Positive Symptoms at 18 months after randomization. RESULTS: Patients treated with cognitive therapy showed a clinically significant mean improvement in global functioning from baseline to 18 months that was greater than the improvement seen with standard treatment (within-group Cohen d, 1.36 vs 0.06, respectively; adjusted mean [SE], 58.3 [3.30] vs 47.9 [3.60], respectively; P = .03; between-group d = 0.56). Patients receiving cognitive therapy as compared with those receiving standard treatment also showed a greater mean reduction in avolition-apathy (adjusted mean [SE], 1.66 [0.31] vs 2.81 [0.34], respectively; P = .01; between-group d = -0.66) and positive symptoms (hallucinations, delusions, disorganization) (adjusted mean [SE], 9.4 [3.3] vs 18.2 [3.8], respectively; P = .04; between-group d = -0.46) at 18 months. Age was controlled in the analyses, and there were no meaningful group differences in baseline antipsychotic medications (class or dosage) or in medication changes during the course of the trial. CONCLUSION: Cognitive therapy can be successful in promoting clinically meaningful improvements in functional outcome, motivation, and positive symptoms in low-functioning patients with significant cognitive impairment. Trial Registration  clinicaltrials.gov Identifier: NCT00350883.

Assessment of cognitive insight: a qualitative review.

The concept of cognitive insight was introduced in 2004 to describe the capacity of patients with psychosis to distance themselves from their psychotic experiences, reflect on them, and respond to corrective feedback. The Beck Cognitive Insight Scale (BCIS) was developed to evaluate these aspects of cognitive flexibility and to complement scales that describe the lack of awareness of mental illness and its characteristics. The BCIS has generated a moderate research literature, which is the subject of the current review. Several independent groups have demonstrated that the BCIS is reliable, demonstrates convergent and construct validity, and distinguishes patients with psychosis from healthy controls and patients without psychosis. While the majority of the studies have focused on the relationship of the BCIS to delusions, several have examined its relationship to negative symptoms, depression, anxiety, and functional outcome. Cognitive insight has predicted positive gains in psychotherapy of psychosis, and improvement in cognitive insight has been correlated with improvement in delusional beliefs. Finally, preliminary findings relate neurocognition, metacognition, and social cognition, as well as reduced hippocampal volume to cognitive insight. A heuristic framework is presented to guide future research.

Training and Consultation in Evidence-Based Psychosocial Treatments in Public Mental Health Settings: The ACCESS Model.

We present a model of training in evidence-based psychosocial treatments (EBTs). The ACCESS (assess and adapt, convey basics, consult, evaluate, study outcomes, sustain) model integrates principles and findings from adult education and training literatures, research, and practical suggestions based on a community-based clinician training program. Descriptions of the steps are provided as a means of guiding implementation efforts and facilitating training partnerships between public mental health agencies and practitioners of EBTs.

Negative performance beliefs and negative symptoms in individuals at ultra-high risk of psychosis: a preliminary study.

BACKGROUND: Negative beliefs regarding task performance have been shown to correlate with negative symptom severity in patients with chronic schizophrenia. We conducted a pilot study to determine whether the association also exists in individuals at ultra-high risk of psychosis. SAMPLING AND METHODS: The sample consisted of 38 individuals at ultra-high risk of psychosis and 51 controls. All participants completed the Abbreviated Dysfunctional Attitudes Scale; the ultra-high-risk participants were assessed with the Positive and Negative Syndrome Scale. RESULTS: High-risk participants endorsed negative performance beliefs to a greater extent than controls and these beliefs were associated with greater negative symptom severity, independent of depression and positive symptoms. CONCLUSIONS: The findings are consistent with previous results in chronic patients, and suggest that negative performance beliefs may be a promising psychological factor worthy of further attention in individuals at high risk of psychosis. Longitudinal research with more comprehensive assessment is needed to elucidate the potential role of negative performance beliefs in this population.

Cognitive behavioral therapy of negative symptoms.

Negative symptoms account for much of the functional disability associated with schizophrenia and often persist despite pharmacological treatment. Cognitive behavioral therapy (CBT) is a promising adjunctive psychotherapy for negative symptoms. The treatment is based on a cognitive formulation in which negative symptoms arise and are maintained by dysfunctional beliefs that are a reaction to the neurocognitive impairment and discouraging life events frequently experienced by individuals with schizophrenia. This article outlines recent innovations in tailoring CBT for negative symptoms and functioning, including the use of a strong goal-oriented recovery approach, in-session exercises designed to disconfirm dysfunctional beliefs, and adaptations to circumvent neurocognitive and engagement difficulties. A case illustration is provided.

Randomized controlled trial of cognitive behavioral social skills training for older people with schizophrenia: 12-month follow-up.

OBJECTIVE: There is an increasing need for empirically validated psychotherapy interventions that improve functioning in older people with schizophrenia. We developed a 24-session weekly group therapy intervention labeled Cognitive Behavioral Social Skills Training (CBSST), which combined cognitive-behavioral therapy with social skills and problem-solving training to improve functioning. METHOD: We previously reported end-of-treatment findings from a randomized controlled trial that compared treatment as usual (TAU) with TAU plus group CBSST in 76 outpatients, 42 to 74 years of age, with schizophrenia or schizoaffective disorder (DSM-IV criteria). Twelve-month follow-up results of that trial (conducted from October 1999 to September 2004) are reported here. Blind raters obtained assessments of CBSST skill mastery, functioning, psychotic and depressive symptoms, and cognitive insight (belief flexibility). RESULTS: The significantly greater skill acquisition and self-reported performance of living skills in the community seen in CBSST versus TAU patients at the end of treatment were maintained at 12-month follow-up (p < or = .05). Participants in CBSST also showed significantly greater cognitive insight at the end of treatment relative to TAU, but this improvement was not maintained at follow-up. The treatment-group effect was not significant for symptoms at any assessment point; however, symptoms were not the primary treatment target in this stable outpatient sample. CONCLUSION: Older people with very chronic schizophrenia were able to learn and maintain new skills with CBSST and showed improved self-reported functioning 1 year after the treatment ended. Longer treatment and/or booster sessions may be required to maintain gains in cognitive insight.