VA Capitol Health Care Network

Social cognition has become a high priority area for the study of schizophrenia. However, despite developments in this area, progress remains limited by inconsistent terminology and differences in the way social cognition is measured. To address these obstacles, a consensus-building meeting on social cognition in schizophrenia was held at the National Institute of Mental Health in March 2006. Agreement was reached on several points, including definitions of terms, the significance of social cognition for schizophrenia research, and suggestions for future research directions. The importance of translational interdisciplinary research teams was emphasized. The current article presents a summary of these discussions.

In light of the large number of studies published since the 2004 update of Schizophrenia Patient Outcomes Research Team psychopharmacological treatment recommendations, we conducted an extensive literature review to determine whether the current psychopharmacological treatment recommendations required revision and whether there was sufficient evidence to warrant new treatment recommendations for prespecified outcomes of interest. We reviewed over 400 articles, which resulted in 16 treatment recommendations: the revision of 11 previous treatment recommendations and 5 new treatment recommendations. Three previous treatment recommendations were eliminated. There were 13 interventions and/or outcomes for which there was insufficient evidence for a treatment recommendation, and a statement was written to summarize the current level of evidence and identify important gaps in our knowledge that need to be addressed. In general, there was considerable consensus among the Psychopharmacology Evidence Review Group and the expert consultants. Two major areas of contention concerned whether there was sufficient evidence to recommend specific dosage ranges for the acute and maintenance treatment of first-episode and multi-episode schizophrenia and to endorse the practice of switching antipsychotics for the treatment of antipsychotic-related weight gain. Finally, there continue to be major gaps in our knowledge, including limited information on (1) the use of adjunctive pharmacological agents for the treatment of persistent positive symptoms or other symptom domains of psychopathology, including anxiety, cognitive impairments, depressive symptoms, and persistent negative symptoms and (2) the treatment of co-occurring substance or medical disorders that occur frequently in individuals with schizophrenia.

The participants in the NIMH-MATRICS Consensus Development Conference on Negative Symptoms recommended that an instrument be developed that measured blunted affect, alogia, asociality, anhedonia, and avolition. The Brief Negative Symptom Scale (BNSS) is a 13-item instrument designed for clinical trials and other studies that measures these 5 domains. The interrater, test-retest, and internal consistency of the instrument were strong, with respective intraclass correlation coefficients of 0.93 for the BNSS total score and values of 0.89-0.95 for individual subscales. Comparisons with positive symptoms and other negative symptom instruments supported the discriminant and concurrent validity of the instrument.

CONTEXT: In focusing on potentially localizable cognitive impairments, the schizophrenia meta-analytic literature has overlooked the largest single impairment: on digit symbol coding tasks. OBJECTIVE: To compare the magnitude of the schizophrenia impairment on coding tasks with impairments on other traditional neuropsychological instruments. DATA SOURCES: MEDLINE and PsycINFO electronic databases and reference lists from identified articles. STUDY SELECTION: English-language studies from 1990 to present, comparing performance of patients with schizophrenia and healthy controls on coding tasks and cognitive measures representing at least 2 other cognitive domains. Of 182 studies identified, 40 met all criteria for inclusion in the meta-analysis. DATA EXTRACTION: Means, standard deviations, and sample sizes were extracted for digit symbol coding and 36 other cognitive variables. In addition, we recorded potential clinical moderator variables, including chronicity/severity, medication status, age, and education, and potential study design moderators, including coding task variant, matching, and study publication date. DATA SYNTHESIS: Main analyses synthesized data from 37 studies comprising 1961 patients with schizophrenia and 1444 comparison subjects. Combination of mean effect sizes across studies by means of a random effects model yielded a weighted mean effect for digit symbol coding of g = -1.57 (95% confidence interval, -1.66 to -1.48). This effect compared with a grand mean effect of g = -0.98 and was significantly larger than effects for widely used measures of episodic memory, executive functioning, and working memory. Moderator variable analyses indicated that clinical and study design differences between studies had little effect on the coding task effect. Comparison with previous meta-analyses suggested that current results were representative of the broader literature. Subsidiary analysis of data from relatives of patients with schizophrenia also suggested prominent coding task impairments in this group. CONCLUSION: The 5-minute digit symbol coding task, reliable and easy to administer, taps an information processing inefficiency that is a central feature of the cognitive deficit in schizophrenia and deserves systematic investigation.

The Schizophrenia Patient Outcomes Research Team (PORT) psychosocial treatment recommendations provide a comprehensive summary of current evidence-based psychosocial treatment interventions for persons with schizophrenia. There have been 2 previous sets of psychosocial treatment recommendations (Lehman AF, Steinwachs DM. Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations. Schizophr Bull. 1998;24:1-10 and Lehman AF, Kreyenbuhl J, Buchanan RW, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2003. Schizophr Bull. 2004;30:193-217). This article reports the third set of PORT recommendations that includes updated reviews in 7 areas as well as adding 5 new areas of review. Members of the psychosocial Evidence Review Group conducted reviews of the literature in each intervention area and drafted the recommendation or summary statement with supporting discussion. A Psychosocial Advisory Committee was consulted in all aspects of the review, and an expert panel commented on draft recommendations and summary statements. Our review process produced 8 treatment recommendations in the following areas: assertive community treatment, supported employment, cognitive behavioral therapy, family-based services, token economy, skills training, psychosocial interventions for alcohol and substance use disorders, and psychosocial interventions for weight management. Reviews of treatments focused on medication adherence, cognitive remediation, psychosocial treatments for recent onset schizophrenia, and peer support and peer-delivered services indicated that none of these treatment areas yet have enough evidence to merit a treatment recommendation, though each is an emerging area of interest. This update of PORT psychosocial treatment recommendations underscores both the expansion of knowledge regarding psychosocial treatments for persons with schizophrenia at the same time as the limitations in their implementation in clinical practice settings.

Schizophrenia has traditionally been viewed as a chronic condition with a very pessimistic outlook, but that assumption may not be valid. There has been a growing consumer movement among people with schizophrenia that has challenged both the traditional perspective on the course of illness and the associated assumptions about the possibility of people with the illness living a productive and satisfying life. This new conception of the illness is supported by long-term studies that suggest that as much as 50% of people with the illness have good outcomes. There has also been a change in political and public health perspectives of the illness, stimulated in part by the President's New Freedom Commission on Mental Health. The purpose of this article is to provide an overview of some key themes about the recovery concept, as applied to schizophrenia. The article will address 3 questions: (1) What is recovery? (2) Is recovery possible? and (3) What are the implications of a recovery model for a scientific approach to treatment (ie, the use of evidence-based practices)? Scientific and consumer models of recovery are described, and commonalities and differences are discussed. Priorities for future research are suggested.

Patients with schizophrenia demonstrate deficits in motivation and learning that suggest impairment in different aspects of the reward system. In this article, we present the results of 8 converging experiments that address subjective reward experience, the impact of rewards on decision making, and the role of rewards in guiding both rapid and long-term learning. All experiments compared the performance of stably treated outpatients with schizophrenia and demographically matched healthy volunteers. Results to date suggest (1) that patients have surprisingly normal experiences of positive emotion when presented with evocative stimuli, (2) that patients show reduced correlation, compared with controls, between their own subjective valuation of stimuli and action selection, (3) that decision making in patients appears to be compromised by deficits in the ability to fully represent the value of different choices and response options, and (4) that rapid learning on the basis of trial-to-trial feedback is severely impaired whereas more gradual learning may be surprisingly preserved in many paradigms. The overall pattern of findings suggests compromises in the orbital and dorsal prefrontal structures that play a critical role in the ability to represent the value of outcomes and plans. In contrast, patients often (but not always) approach normal performance levels on the slow learning achieved by the integration of reinforcement signals over many trials, thought to be mediated by the basal ganglia.

The Schizophrenia Patient Outcomes Research Team (PORT) project has played a significant role in the development and dissemination of evidence-based practices for schizophrenia. In contrast to other clinical guidelines, the Schizophrenia PORT Treatment Recommendations, initially published in 1998 and first revised in 2003, are based primarily on empirical data. Over the last 5 years, research on psychopharmacologic and psychosocial treatments for schizophrenia has continued to evolve, warranting an update of the PORT recommendations. In consultation with expert advisors, 2 Evidence Review Groups (ERGs) identified 41 treatment areas for review and conducted electronic literature searches to identify all clinical studies published since the last PORT literature review. The ERGs also reviewed studies preceding 2002 in areas not covered by previous PORT reviews, including smoking cessation, substance abuse, and weight loss. The ERGs reviewed over 600 studies and synthesized the research evidence, producing recommendations for those treatments for which the evidence was sufficiently strong to merit recommendation status. For those treatments lacking empirical support, the ERGs produced parallel summary statements. An Expert Panel consisting of 39 schizophrenia researchers, clinicians, and consumers attended a conference in November 2008 in which consensus was reached on the state of the evidence for each of the treatment areas reviewed. The methods and outcomes of the update process are presented here and resulted in recommendations for 16 psychopharmacologic and 8 psychosocial treatments for schizophrenia. Another 13 psychopharmacologic and 4 psychosocial treatments had insufficient evidence to support a recommendation, representing significant unmet needs in important treatment domains.

Disengagement from mental health services can lead to devastating consequences for individuals with schizophrenia and other serious mental illnesses who require ongoing treatment. We review the extent and correlates of dropping out of mental health treatment for individuals with schizophrenia and suggest strategies for facilitating treatment engagement. Although rates vary across studies, reviews of the literature suggest that up to one-third of individuals with serious mental illnesses who have had some contact with the mental health service system disengage from care. Younger age, male gender, ethnic minority background, and low social functioning have been consistently associated with disengagement from mental health treatment. Individuals with co-occurring psychiatric and substance use disorders, as well as those with early-onset psychosis, are at particularly high risk of treatment dropout. Engagement strategies should specifically target these high-risk groups, as well as high-risk periods, including following an emergency room or hospital admission and the initial period of treatment. Interventions to enhance engagement in mental health treatment range from low-intensity interventions, such as appointment reminders, to high-intensity interventions, such as assertive community treatment. Disengagement from treatment may reflect the consumer's perspective that treatment is not necessary, is not meeting their needs, or is not being provided in a collaborative manner. An emerging literature on patient-centered care and shared decision making in psychiatry provides suggestive evidence that efforts to enhance client-centered communication and promote individuals' active involvement in mental health treatment decisions can also improve engagement in treatment.

OBJECTIVE: To quantify the association between olanzapine and diabetes. DESIGN: Population based nested case-control study. SETTING: United Kingdom based General Practice Research Database comprising 3.5 million patients followed between 1987 and 2000. PARTICIPANTS: 19 637 patients who had been diagnosed as having and treated for schizophrenia. 451 incident cases of diabetes were matched with 2696 controls. MAIN OUTCOME MEASURES: Diagnosis and treatment of diabetes. RESULTS: Patients taking olanzapine had a significantly increased risk of developing diabetes than non-users of antipsychotics (odds ratio 5.8, 95% confidence interval 2.0 to 16.7) and those taking conventional antipsychotics (4.2, 1.5 to 12.2). Patients taking risperidone had a non-significant increased risk of developing diabetes than non-users of antipsychotics (2.2, 0.9 to 5.2) and those taking conventional antipsychotics (1.6, 0.7 to 3.8). CONCLUSION: Olanzapine is associated with a clinically important and significant increased risk of diabetes.

OBJECTIVE: Telepsychiatry is an increasingly common method of providing psychiatric care, but randomized trials of telepsychiatric treatment compared to in-person treatment have not been done. The primary objective of this study was to compare treatment outcomes of patients with depressive disorders treated remotely by means of telepsychiatry to outcomes of depressed patients treated in person. Secondary objectives were to determine if patients' rates of adherence to and satisfaction with treatment were as high with telepsychiatric as with in-person treatment and to compare costs of telepsychiatric treatment to costs of in-person treatment. METHOD: In this randomized, controlled trial, 119 depressed veterans referred for outpatient treatment were randomly assigned to either remote treatment by means of telepsychiatry or in-person treatment. Psychiatric treatment lasted 6 months and consisted of psychotropic medication, psychoeducation, and brief supportive counseling. Patients' treatment outcomes, satisfaction, and adherence and the costs of treatment were compared between the two conditions. RESULTS: Hamilton Depression Rating Scale and Beck Depression Inventory scores improved over the treatment period and did not differ between treatment groups. The two groups were equally adherent to appointments and medication treatment. No between-group differences in dropout rates or patients' ratings of satisfaction with treatment were found. Telepsychiatry was more expensive per treatment session, but this difference disappeared if the costs of psychiatrists' travel to remote clinics more than 22 miles away from the medical center were considered. Telepsychiatry did not increase the overall health care resource consumption of the patients during the study period. CONCLUSIONS: Remote treatment of depression by means of telepsychiatry and in-person treatment of depression have comparable outcomes and equivalent levels of patient adherence, patient satisfaction, and health care cost.

OBJECTIVE: With growing awareness of the impact of mental illness self-stigma, interest has arisen in the development of interventions to combat it. The present article briefly reviews and compares interventions targeting self-stigma to clarify the similarities and important differences between the interventions. METHOD: We conducted a narrative review of published literature on interventions targeting self-stigma. RESULTS: Six intervention approaches (Healthy Self-Concept, Self-Stigma Reduction Program, Ending Self-Stigma, Narrative Enhancement and Cognitive Therapy, Coming Out Proud, and Anti-Stigma Photo-Voice Intervention) were identified and are discussed, and data is reviewed on format, group-leader backgrounds, languages, number of sessions, primary mechanisms of action, and the current state of data on their efficacy. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: We conclude with a discussion of common elements and important distinctions between the interventions and a consideration of which interventions might be best suited to particular populations or settings.

OBJECTIVES: Cognitive impairment is frequently observed among individuals with bipolar disorder during acute and euthymic phases of the illness. The purpose of this study was to provide an updated meta-analysis on the neuropsychological functioning of euthymic bipolar disorder individuals and to explore study design, demographic, and clinical variables that could moderate observed effects. METHODS: Searches were conducted on Medline and PsychInfo databases and 28 studies were selected that met inclusion criteria. A total of 28 cognitive variables were examined in the meta-analysis. The effects of four continuous (age, percent female, education, and illness duration) and two dichotomous (clinical course and diagnostic rigor) moderator variables were explored. RESULTS: Compared to controls, euthymic bipolar disorder individuals demonstrated impaired neuropsychological functioning across almost all domains, with medium-large effect sizes. Notably, vocabulary and word reading did not differ from controls. Sex did not impact neuropsychological functioning, and neuropsychological impairment decreased as education increased. Contrary to expectations, age and illness duration were negatively correlated with cognitive impairment. Diagnostic rigor of euthymia did not appear to impact effect sizes; however, clinical course received some tentative support as a moderator variable. CONCLUSIONS: Current results suggest that generalized, rather than specific, cognitive impairment characterizes euthymic bipolar disorder. Age, illness duration, education, and clinical course may moderate these broad cognitive effects. Against this general impairment backdrop, there may be a relative preservation of crystallized verbal ability.

Although physical inactivity is a leading cause of death and the Surgeon General recommends regular moderate physical activity, many Americans are inactive. Because of their increased burden of obesity and diabetes, people with severe mental illness (SMI) especially may benefit from physical activity, yet little is known about the prevalence and types of physical activity in people with SMI. We surveyed outpatients with schizophrenia and affective disorders at two psychiatric centers in Maryland and compared physical activity patterns to an age-gender-race-matched national sample (National Health and Nutrition Examination Survey III) of the general population. We found that people with SMI are overall less physically active than the general population, although the proportion with recommended physical activity levels was equal. The participants with SMI were more likely to walk as their sole form of physical activity. Within the SMI group, those without regular social contact and women had higher odds of being inactive.

CONTEXT: Drug abuse by people with severe mental disorder is a significant public health problem for which there is no empirically validated treatment. OBJECTIVE: To evaluate the efficacy of a new behavioral treatment for drug abuse in this population: Behavioral Treatment for Substance Abuse in Severe and Persistent Mental Illness (BTSAS). DESIGN: Participants were randomly assigned to 6 months of treatment in either BTSAS or a manualized control condition: Supportive Treatment for Addiction Recovery (STAR). SETTING: Treatment was conducted in community-based outpatient clinics and a Veterans Affairs medical center in Baltimore, Md. PARTICIPANTS: Participants were 129 stabilized outpatients meeting DSM criteria for drug dependence (cocaine, heroin, or cannabis) and serious mental illness: 39.5% met DSM-IV criteria for schizophrenia or schizoaffective disorder; 55.8%, for major affective disorders; and the remainder met criteria for severe and persistent mental illness and other Axis I disorders. INTERVENTIONS: Both treatments were administered by trained health care professionals in small groups, twice a week for 6 months. The BTSAS program is a social learning intervention that includes motivational interviewing, a urinalysis contingency, and social skills training. The control condition, STAR, is a supportive group discussion treatment. Main Outcome Measure The primary outcome measure was urinalysis results from twice-weekly treatment sessions. RESULTS: The BTSAS program was significantly more effective than STAR in percentage of clean urine test results, survival in treatment, and attendance at sessions. The BTSAS program also had significant effects on important community-functioning variables, including hospitalization; money available for living expenses; and quality of life. CONCLUSIONS: The BTSAS program is an efficacious treatment. Further work needs to be done to increase the proportion of eligible patients who are able to become engaged in treatment.

OBJECTIVES: The investigators aimed to examine the prevalence of internalized stigma among individuals with serious mental illness and to construct and test a hypothesized model of the interrelationships among internalized stigma, self-concept, and psychiatric symptoms. METHODS: One hundred individuals, most of whom were African American and had a diagnosis of serious mental illness, were receiving mental health services from one of three community outpatient mental health programs or one Veterans Affairsmedical center. They completed an interview that included measures of internalized stigma, psychiatric symptoms, self-esteem, selfefficacy, and recovery orientation. Structural equation modeling (SEM) was used to examine the interrelationships among these variables. RESULTS: Thirty-five percent of participants reported moderate to severe levels of internalized stigma, which was not significantly associated with any demographic variable or diagnosis. However, greater internalized stigma was associated with lower levels of self-esteem, self-efficacy, and recovery orientation, as well as with more severe psychiatric symptoms. The SEM produced a nonsignificant chi square statistic and other fit indices indicative of a good model fit (goodness-of-fit index=.96, root mean square error of approximation=.011). CONCLUSIONS: Results suggest that internalized stigma was prevalent and problematic among individuals with serious mental illness. There may be multiple pathways through which stigma and discrimination lead to negative outcomes, suggesting that interventions to reduce internalized stigma need to target multiple points along these pathways in order to be effective.

BACKGROUND: To assess the direct cost of relapse and the predictors of relapse during the treatment of patients with schizophrenia in the United States. METHODS: Data were drawn from a prospective, observational, noninterventional study of schizophrenia in the United States (US-SCAP) conducted between 7/1997 and 9/2003. Patients with and without relapse in the prior 6 months were compared on total direct mental health costs and cost components in the following year using propensity score matching method. Baseline predictors of subsequent relapse were also assessed. RESULTS: Of 1,557 participants with eligible data, 310 (20%) relapsed during the 6 months prior to the 1-year study period. Costs for patients with prior relapse were about 3 times the costs for patients without prior relapse. Relapse was associated with higher costs for inpatient services as well as for outpatient services and medication. Patients with prior relapse were younger and had onset of illness at earlier ages, poorer medication adherence, more severe symptoms, a higher prevalence of substance use disorder, and worse functional status. Inpatient costs for patients with a relapse during both the prior 6 months and the follow-up year were 5 times the costs for patients with relapse during the follow-up year only. Prior relapse was a robust predictor of subsequent relapse, above and beyond information about patients' functioning and symptom levels. CONCLUSIONS: Despite the historical decline in utilization of psychiatric inpatient services, relapse remains an important predictor of subsequent relapse and treatment costs for persons with schizophrenia.

Background The organization of mental disorders into 16 DSM-IV and 10 ICD-10 chapters is complex and based on clinical presentation. We explored the feasibility of a more parsimonious meta-structure based on both risk factors and clinical factors. Method Most DSM-IV disorders were allocated to one of five clusters as a starting premise. Teams of experts then reviewed the literature to determine within-cluster similarities on 11 predetermined validating criteria. Disorders were included and excluded as determined by the available data. These data are intended to inform the grouping of disorders in the DSM-V and ICD-11 processes. Results The final clusters were neurocognitive (identified principally by neural substrate abnormalities), neurodevelopmental (identified principally by early and continuing cognitive deficits), psychosis (identified principally by clinical features and biomarkers for information processing deficits), emotional (identified principally by the temperamental antecedent of negative emotionality), and externalizing (identified principally by the temperamental antecedent of disinhibition). Conclusions Large groups of disorders were found to share risk factors and also clinical picture. There could be advantages for clinical practice, public administration and research from the adoption of such an organizing principle.

Recently, attention to the assessment and treatment of functional disability has increased notably. It is widely understood that impairments in everyday living skills, including independent living skills, social functions, vocational functioning, and self-care, are present in people with schizophrenia. It has also become clear recently that assessment of these skills can pose substantial challenges. These challenges include selection of meaningful short-term outcome measures and avoiding bias and reduced validity in the data. Self-report, direct observation, and informant reports of everyday disability all have certain advantages but appear to be inferior to direct assessment of skills with performance-based measures. This review outlines the issues associated with the assessment of functional skills and everyday functioning and provides a description of the strengths and weaknesses of these approaches. We conclude that direct assessment of functional capacity has substantial advantages over other measures and may actually provide a more direct and valid estimate of functional disability than performance on the more distal neuropsychological assessment measures.

OBJECTIVE: To study the distribution and correlates of body mass index (BMI) among individuals with serious mental illness. METHOD: A total of 169 participants were recruited from randomly selected out-patients receiving community-based psychiatric care and were interviewed with items from the National Health and Nutrition Examination Survey (NHANES) III. Their BMI was compared with that of 2404 matched individuals from the NHANES data set. RESULTS: The distribution of BMI in the psychiatric sample significantly differed from that of the comparison group; 50% of women and 41% of men were obese compared with 27% and 20% in the comparison group. Within the psychiatric sample, higher BMI was associated with current hypertension and diabetes, a wish to weigh less, and reduced health-related functioning. CONCLUSION: Obesity is more prevalent among individuals with serious mental illness than in demographically matched individuals from the US general population. Among persons with mental illness, obesity is associated with co-occurring health problems.