The Use of Individually Tailored Environmental Supports to Improve Medication Adherence and Outcomes in Schizophrenia

Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
Schizophrenia Bulletin (Impact Factor: 8.45). 05/2008; 34(3):483-93. DOI: 10.1093/schbul/sbm111
Source: PubMed


Cognitive adaptation training (CAT) is a psychosocial treatment that uses environmental supports such as signs, checklists, alarms, and the organization of belongings to cue and sequence adaptive behaviors in the home. Ninety-five outpatients with schizophrenia (structured clinical interview for diagnosis, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) were randomly assigned to (1) Full-CAT (CAT focused on many aspects of community adaptation including grooming, care of living quarters, leisure skills, social and role performance, and medication adherence), (2) Pharm-CAT (CAT focused only on medication and appointment adherence), or (3) treatment as usual (TAU). Treatment lasted for 9 months, and patients were followed for 6 months after the withdrawal of home visits. Medication adherence (assessed during unannounced, in-home pill counts) and functional outcomes were assessed at 3-month intervals. Results of mixed-effects regression models indicated that both CAT and Pharm-CAT treatments were superior to TAU for improving adherence to prescribed medication (P < .0001). Effects on medication adherence remained significant when home visits were withdrawn. Full-CAT treatment improved functional outcome relative to Pharm-CAT and TAU (P < .0001). However, differences for functional outcome across groups decreased following the withdrawal of home visits and were no longer statistically significant at the 6-month follow-up. Survival time to relapse or significant exacerbation was significantly longer in both CAT and Pharm-CAT in comparison to TAU (.004). Findings indicate that supports targeting medication adherence can improve and maintain this behavior. Comprehensive supports targeting multiple domains of functioning are necessary to improve functional outcomes. Maintenance of gains in functional outcome may require some form of continued intervention.

Download full-text


Available from: Pamela M Diamond
  • Source
    • "with respect to adaptive functioning (e.g. Velligan et al., 2000) and medication adherence (Velligan et al., 2008b). It can be argued that CAT should also lead to functional improvements in schizophrenia patients living elsewhere (Quee et al., 2012a). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Cognitive Adaptation Training (CAT) improves functional outcomes in schizophrenia outpatients living in the United States. The effectiveness of CAT for patients living outside the US as well as for long-term hospitalized patients remains to be determined. In addition, it has not yet been studied whether CAT can be successful if patients receive the treatment from psychiatric nurses. This pilot study investigated the effectiveness and feasibility of CAT as a nursing intervention in the Netherlands. Thirty schizophrenia patients (long-term hospitalized patients: 63%) participated in this study. Sixteen patients received treatment as usual (TAU)+CAT, and fourteen patients received TAU. Patients in CAT participated in the treatment for eight months, consisting of weekly home-visits by a psychiatric nurse, supervised by a psychologist. After eight months, CAT interventions were integrated in the usual treatment. Outcome measures were the Multnomah Community Ability Scale (MCAS), the Social and Occupational Functioning Scale (SOFAS), and the Negative Symptom Assessment-Motivation subscale (NSA-M). For inpatients, work-related activities were also tracked for 16months after baseline. Patients receiving TAU+CAT had better scores on the MCAS (trend), compared to TAU patients. Moreover, inpatients' work-related activities increased in TAU+CAT, relative to TAU inpatients, reaching significance after ten months. Improvements on the SOFAS and NSA-M were not significant. These results indicate that CAT as a nursing intervention may improve outcomes in patients with schizophrenia living in the Netherlands, including long-term hospitalized patients. However, since the current study was designed for exploratory purposes, larger randomized controlled studies are needed to confirm our results and to investigate the long-term effects of CAT as a nursing intervention systematically.
    Full-text · Article · Jul 2014 · Schizophrenia Research
  • Source
    • "While there is evidence of clinically significant improvement in the domains described above, one shortcoming with CAT lies in the maintenance of gains after the intervention is withdrawn. For example, in a trial by Velligan et al. (2008a), it was found that control-treatment differences in functional outcome were no longer present 6 months "
    [Show abstract] [Hide abstract]
    ABSTRACT: Cognitive adaptation training (CAT) is a home-based, manualized treatment that utilizes environmental supports to improve target behaviors and functional outcomes in persons with schizophrenia. Although clinical trials have shown CAT to be effective across functional, clinical, and treatment adherence domains, when the intervention is withdrawn clients experience significant declines. The aim of the current study was to test a modified version of CAT, which decreases the duration of intensive CAT intervention while utilizing ongoing case management-supported CAT to maintain the fundamental components of the treatment. Twenty-three people participated in an outcome study of the modified version of CAT, evaluating improvements after 4 months of CAT specialist intervention and after an additional 5 months of case manager support. Analysis revealed significant improvements in adaptive functioning, psychiatric symptomatology, and goal attainment, which were maintained throughout case management follow-up. This suggests that an intervention that has previously demonstrated good functional outcomes in randomized trials might sustain its impacts in an abbreviated format with support from existing case managers.
    Full-text · Article · Jun 2014 · Schizophrenia Research
  • Source
    • "The " compensatory " treatments try to eliminate or to bypass the specific cognitive deficit, using the subject's residual cognitive abilities and/or the environmental resources. Indeed, the manipulation of the environment is a compensatory technique acting and operating changes in the environment in order to influence and facilitate the cognitive functions, for example, by simplifying the patient's tasks [18]. On the other hand, the " restorative " methods are based on knowledge deriving from neurosciences, in particular neuronal plasticity, and have the objective to correct a specific deficit trying to repair the specific underlying compromised function using the capacity of the brain to develop and repair itself throughout the whole life [10] [14]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Objectives. This study is aimed to review the current scientific literature on cognitive remediation in schizophrenia. In particular, the main structured protocols of cognitive remediation developed for schizophrenia are presented and the main results reported in recent meta-analyses are summarized. Possible benefits of cognitive remediation in the early course of schizophrenia and in subjects at risk for psychosis are also discussed. Methods. Electronic search of the relevant studies which appeared in the PubMed database until April 2013 has been performed and all the meta-analyses and review articles on cognitive remediation in schizophrenia have been also taken into account. Results. Numerous intervention programs have been designed, applied, and evaluated, with the objective of improving cognition and social functioning in schizophrenia. Several quantitative reviews have established that cognitive remediation is effective in reducing cognitive deficits and in improving functional outcome of the disorder. Furthermore, the studies available support the usefulness of cognitive remediation when applied in the early course of schizophrenia and even in subjects at risk of the disease. Conclusions. Cognitive remediation is a promising approach to improve real-world functioning in schizophrenia and should be considered a key strategy for early intervention in the psychoses.
    Full-text · Article · Dec 2013
Show more