[Show abstract][Hide abstract] ABSTRACT: According to current treatment guidelines for Complex PTSD (cPTSD), psychotherapy for adults with cPTSD should start with a "stabilization phase." This phase, focusing on teaching self-regulation strategies, was designed to ensure that an individual would be better able to tolerate trauma-focused treatment. The purpose of this paper is to critically evaluate the research underlying these treatment guidelines for cPTSD, and to specifically address the question as to whether a phase-based approach is needed. As reviewed in this paper, the research supporting the need for phase-based treatment for individuals with cPTSD is methodologically limited. Further, there is no rigorous research to support the views that: (1) a phase-based approach is necessary for positive treatment outcomes for adults with cPTSD, (2) front-line trauma-focused treatments have unacceptable risks or that adults with cPTSD do not respond to them, and (3) adults with cPTSD profit significantly more from trauma-focused treatments when preceded by a stabilization phase. The current treatment guidelines for cPTSD may therefore be too conservative, risking that patients are denied or delayed in receiving conventional evidence-based treatments from which they might profit.
Full-text · Article · Feb 2016 · Depression and Anxiety
[Show abstract][Hide abstract] ABSTRACT: This study compares the cost-effectiveness of Navigate (NAV), a comprehensive, multidisciplinary, team-based treatment approach
for first episode psychosis (FEP) and usual Community Care (CC) in a cluster randomization trial. Patients at 34 community
treatment clinics were randomly assigned to either NAV (N = 223) or CC (N = 181) for 2 years. Effectiveness was measured as a one standard deviation change on the Quality of Life Scale (QLS-SD).
Incremental cost effectiveness ratios were evaluated with bootstrap distributions. The Net Health Benefits Approach was used
to evaluate the probability that the value of NAV benefits exceeded its costs relative to CC from the perspective of the health
care system. The NAV group improved significantly more on the QLS and had higher outpatient mental health and antipsychotic
medication costs. The incremental cost-effectiveness ratio was $12 081/QLS-SD, with a .94 probability that NAV was more cost-effective
than CC at $40 000/QLS-SD. When converted to monetized Quality Adjusted Life Years, NAV benefits exceeded costs, especially
at future generic drug prices.
No preview · Article · Jan 2016 · Schizophrenia Bulletin
[Show abstract][Hide abstract] ABSTRACT: Despite advances in schizophrenia treatment, symptom relapses and rehospitalizations impede recovery for many people and are a principal driver of the high cost of care. Technology-delivered or technology-enhanced treatment may be a cost-effective way to provide flexible, personalized evidence-based treatments directly to people in their homes and communities. However, evidence for the safety, acceptability, and efficacy of such interventions is only now being established. The authors of this Open Forum describe a novel, technology-based approach to prevent relapse after a hospitalization for psychosis, the Health Technology Program (HTP), which they developed. HTP provides in-person relapse prevention planning that directs use of tailored, technology-based treatment based on cognitive-behavioral therapy for psychosis, family psychoeducation for schizophrenia, and prescriber decision support through a Web-based program that solicits information from clients at every visit. Technology-based treatments are delivered through smartphones and computers.
No preview · Article · Jan 2016 · Psychiatric services (Washington, D.C.)
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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.
ClinicalTrials.gov NCT02254733. Date of registration: 25 April 2014.
[Show abstract][Hide abstract] ABSTRACT: Provider competence may affect the impact of a practice. The current study examined this relationship in sixty-three providers engaging in Illness Management and Recovery with 236 consumers. Improving upon previous research, the present study utilized a psychometrically validated competence measure in the ratings of multiple Illness Management and Recovery sessions from community providers, and mapped outcomes onto the theory underlying the practice. Provider competence was positively associated with illness self-management and adaptive coping. Results also indicated baseline self-management skills and working alliance may affect the relationship between competence and outcomes.
No preview · Article · Nov 2015 · Administration and Policy in Mental Health and Mental Health Services Research
[Show abstract][Hide abstract] ABSTRACT: Early intervention treatment programs have begun to play an increasingly important role in improving long-term outcomes for people with psychosis. These programs focus on helping people achieve recovery through reducing the risk of relapse, improving illness self-management skills, and making progress toward a meaningful life. This article describes Individual Resiliency Training (IRT), the individual therapy component of the Recovery After Initial Schizophrenia Episode Early Treatment Program (RAISE-ETP). As part of a comprehensive specialty care program for people with first-episode psychosis (FEP), IRT uses a strengths-based approach that focuses on progress toward individual recovery goals, as well as improving social functioning and overall well-being. IRT addresses recovery by engaging in illness self-management, Cognitive Behavior Therapy for Psychosis, and psychiatric rehabilitation skills. Two illustrative cases show how people can use information and skills within the IRT modules to make progress toward recovery and learn individualized skills to address common challenges. Within a coordinated specialty care program, IRT provides strategies and skills that promote recovery and resiliency, and shows promise toward improved illness outcomes for people with FEP.
[Show abstract][Hide abstract] ABSTRACT: Objective:
The primary aim of this study was to compare the impact of NAVIGATE, a comprehensive, multidisciplinary, team-based treatment approach for first-episode psychosis designed for implementation in the U.S. health care system, with community care on quality of life.
Thirty-four clinics in 21 states were randomly assigned to NAVIGATE or community care. Diagnosis, duration of untreated psychosis, and clinical outcomes were assessed via live, two-way video by remote, centralized raters masked to study design and treatment. Participants (mean age, 23) with schizophrenia and related disorders and ≤6 months of antipsychotic treatment (N=404) were enrolled and followed for ≥2 years. The primary outcome was the total score of the Heinrichs-Carpenter Quality of Life Scale, a measure that includes sense of purpose, motivation, emotional and social interactions, role functioning, and engagement in regular activities.
The 223 recipients of NAVIGATE remained in treatment longer, experienced greater improvement in quality of life and psychopathology, and experienced greater involvement in work and school compared with 181 participants in community care. The median duration of untreated psychosis was 74 weeks. NAVIGATE participants with duration of untreated psychosis of <74 weeks had greater improvement in quality of life and psychopathology compared with those with longer duration of untreated psychosis and those in community care. Rates of hospitalization were relatively low compared with other first-episode psychosis clinical trials and did not differ between groups.
Comprehensive care for first-episode psychosis can be implemented in U.S. community clinics and improves functional and clinical outcomes. Effects are more pronounced for those with shorter duration of untreated psychosis.
Full-text · Article · Oct 2015 · American Journal of Psychiatry
[Show abstract][Hide abstract] ABSTRACT: Effective and scalable lifestyle interventions are needed to address high rates of obesity in people with serious mental illness (SMI). This pilot study evaluated the feasibility of a behavioral weight loss intervention enhanced with peer support and mobile health (mHealth) technology for obese individuals with SMI. The Diabetes Prevention Program Group Lifestyle Balance intervention enhanced with peer support and mHealth technology was implemented in a community mental health setting. Thirteen obese individuals with SMI participated in a pre-post pilot study of the 24-week intervention. Feasibility was assessed by program attendance, and participant satisfaction and suggestions for improving the model. Descriptive changes in weight and fitness were also explored. Overall attendance amounted to approximately half (56 %) of weekly sessions. At 6-month follow-up, 45 % of participants had lost weight, and 45 % showed improved fitness by increasing their walking distance. Participants suggested a number of modifications to increase the relevance of the intervention for people with SMI, including less didactic instruction and more active learning, a simplified dietary component, more in depth technology training, and greater attention to mental health. The principles of standard behavioral weight loss treatment provide a useful starting point for promoting weight loss in people with SMI. However, adaptions to standard weight loss curricula are needed to enhance engagement, participation, and outcomes to respond to the unique challenges of individuals with SMI.
No preview · Article · Oct 2015 · Psychiatric Quarterly
[Show abstract][Hide abstract] ABSTRACT: The focus of community health workers on health disparities in vulnerable communities means that they address issues of poverty, while many recipients of psychiatric rehabilitation services live at or below the poverty line. Their focus on improving health in low-income populations of color is in line with some of our field's biggest challenges at this point in history, including poverty, cultural competence, and health comorbidities. By allying with community health workers we have the opportunity to extend our reach into new neighborhoods as well as to better serve our current clientele. By reaching out to local community health worker programs, conducting cross-training, and exploring new funding opportunities presented by health care reform, we may be able to enrich the multidisciplinary, collaborative ethos that makes psychiatric rehabilitation so relevant and effective. (PsycINFO Database Record
[Show abstract][Hide abstract] ABSTRACT: Effective and scalable interventions are needed to reach a greater proportion of individuals with serious mental illness (SMI) who experience alarmingly high rates of obesity. This pilot study evaluated the feasibility of translating an evidenced-based professional health coach model (In SHAPE) to peer health coaching for overweight and obese individuals with SMI. Key stakeholders collaborated to modify In SHAPE to include a transition from professional health coaching to individual and group-based peer health coaching enhanced by mobile health technology. Ten individuals with SMI were recruited from a public mental health agency to participate in a 6-month feasibility pilot study of the new model. There was no overall significant change in mean weight; however, over half (56 %) of participants lost weight by the end of the intervention with mean weight loss 2.7 ± 2.1 kg. Participants reported high satisfaction and perceived benefits from the program. Qualitative interviews with key stakeholders indicated that the intervention was implemented as planned. This formative research showed that peer health coaching for individuals with SMI is feasible. Further research is needed to evaluate its effectiveness.
No preview · Article · Sep 2015 · Translational Behavioral Medicine
[Show abstract][Hide abstract] ABSTRACT: Cognitive impairment presents a serious and common obstacle to competitive employment for people with severe mental illness, including those who receive supported employment. This study evaluated a cognitive enhancement program to improve cognition and competitive employment in people with mental illness who had not responded to supported employment.
In a randomized controlled trial, 107 people with severe mental illness (46% with schizophrenia or schizoaffective disorder) who had not obtained or kept competitive work despite receiving high-fidelity supported employment were assigned to receive either enhanced supported employment (with specialized cognitive training of employment specialists) or enhanced supported employment plus the Thinking Skills for Work program, a standardized cognitive enhancement program that includes practice of computer cognitive exercises, strategy coaching, and teaching of coping and compensatory strategies. Research assistants tracked competitive employment weekly for 2 years, and assessors blind to treatment assignment evaluated cognitive functioning at baseline, at the end of cognitive enhancement training, and 12 and 24 months after baseline.
Participants in the Thinking Skills for Work group improved more than those in the enhanced supported employment only group on measures of cognitive functioning and had consistently better competitive employment outcomes during the follow-up period, including in jobs obtained (60% compared with 36%), weeks worked (23.9 compared with 9.2), and wages earned ($3,421 compared with $1,728).
The findings suggest that cognitive enhancement interventions can reduce cognitive impairments that are obstacles to work, thereby increasing the number of people who can benefit from supported employment and competitive work.
Full-text · Article · May 2015 · American Journal of Psychiatry
[Show abstract][Hide abstract] ABSTRACT: Current efforts to reduce the increased risk of premature death from preventable cardiovascular disease among adults with
serious mental illness (SMI) through lifestyle change have had limited success. Engaging informal support systems to promote
healthy behaviors in everyday life may increase the effectiveness of health promotion interventions targeting this at-risk
population. In-depth semistructured interviews were conducted with 10 fitness trainers serving adults with SMI in a health
promotion program at community mental health centers to explore their perspectives on the potential of enlisting support from
significant others for health behavior change. Trainers reported that the majority of participants had a relative or significant
other who influenced their health behaviors, and they saw potential value in involving them in efforts to improve health outcomes
by extending support into participants' daily lives. They did not feel qualified to work with families of individuals with
mental illness, but they were willing to partner with providers who had experience in this area. Social workers who practice
with families could play a critical role on health promotion teams addressing cardiovascular risk in adults with SMI by using
their skills and experiences to engage families in supporting a relative through the process of health behavior change.
No preview · Article · Apr 2015 · Health & social work
[Show abstract][Hide abstract] ABSTRACT: Although many studies have reported higher rates of trauma exposure and posttraumatic stress disorder (PTSD) among persons with severe mental illness, the screening, diagnosis, and treatment of PTSD in public mental health centers remain at a suboptimal level and PTSD is often overlooked and untreated. This study used routine PTSD screening and service use data in electronic medical records to determine the association of PTSD, psychiatric symptoms, and service use in a sample of individuals with serious mental illness in a community-based treatment setting.
The sample included 1,834 active clients between January 2007 and November 2010 who were screened for PTSD and who completed the 24-item Behavior and Symptom Identification Scale (BASIS-24). Service data included services provided a year before and a year after the screening date.
PTSD was associated with more severe psychiatric symptoms and increased no-show rates but not with increased service use or use of high-intensity services. PTSD likelihood interacted with race in accounting for elevated scores among African Americans on the psychosis domain of the BASIS-24.
PTSD screening is feasible and recommended in service environments and may contribute significantly to better understanding of racial-ethnic and other differences in service use and diagnostic practices.
[Show abstract][Hide abstract] ABSTRACT: Comprehensive coordinated specialty care programs for first-episode psychosis have been widely implemented in other countries but not in the United States. The National Institute of Mental Health's Recovery After an Initial Schizophrenia Episode (RAISE) initiative focused on the development and evaluation of first-episode treatment programs designed for the U.S. health care system. This article describes the background, rationale, and nature of the intervention developed by the RAISE Early Treatment Program project-known as the NAVIGATE program-with a particular focus on its psychosocial components. NAVIGATE is a team-based, multicomponent treatment program designed to be implemented in routine mental health treatment settings and aimed at guiding people with a first episode of psychosis (and their families) toward psychological and functional health. The core services provided in the NAVIGATE program include the family education program (FEP), individual resiliency training (IRT), supported employment and education (SEE), and individualized medication treatment. NAVIGATE embraces a shared decision-making approach with a focus on strengths and resiliency and on collaboration with clients and family members in treatment planning and reviews. The NAVIGATE program has the potential to fill an important gap in the U.S. health care system by providing a comprehensive intervention specially designed to meet the unique treatment needs of persons recovering from a first episode of psychosis. A cluster-randomized controlled trial comparing NAVIGATE with usual community care has recently been completed.
No preview · Article · Mar 2015 · Psychiatric services (Washington, D.C.)
[Show abstract][Hide abstract] ABSTRACT: Objective: The premise of the National Institute of Mental Health Recovery After an Initial Schizophrenia Episode Early Treatment Program (RAISE-ETP) is to combine state-of-the-Art pharmacologic and psychosocial treatments delivered by a well-trained, multidisciplinary team in order to significantly improve the functional outcome and quality of life for first-episode psychosis patients. The study is being conducted in non-Academic (ie, real-world) treatment settings, using primarily extant reimbursement mechanisms. Method: We developed a treatment model and training program based on extensive literature review and expert consultation. Our primary aim is to compare the experimental intervention to "usual care" on quality of life. Secondary aims include comparisons on remission, recovery, and cost-effectiveness. Patients 15-40 years old with a first episode of schizophrenia, schizoaffective disorder, schizophreniform disorder, psychotic disorder not otherwise specified, or brief psychotic disorder according to DSM-IV and no more than 6 months of treatment with antipsychotic medications were eligible. Patients are followed for a minimum of 2 years, with major assessments conducted by blinded, centralized raters using live, 2-way video. We selected 34 clinical sites in 21 states and utilized cluster randomization to assign 17 sites to the experimental treatment and 17 to usual care. Enrollment began in July 2010 and ended in July 2012 with 404 subjects. The results of the trial will be published separately. The goal of the article is to present both the overall development of the intervention and the design of the clinical trial to evaluate its effectiveness. Conclusions: We believe that we have succeeded in both designing a multimodal treatment intervention that can be delivered in real-world clinical settings and implementing a controlled clinical trial that can provide the necessary outcome data to determine its impact on the trajectory of early phase schizophrenia.
Full-text · Article · Mar 2015 · The Journal of Clinical Psychiatry
[Show abstract][Hide abstract] ABSTRACT: Treatment guidelines suggest distinctive medication strategies for first-episode and multiepisode patients with schizophrenia. To assess the extent to which community clinicians adjust their usual treatment regimens for first-episode patients, the authors examined prescription patterns and factors associated with prescription choice in a national cohort of early-phase patients.
Prescription data at study entry were obtained from 404 participants in the Recovery After an Initial Schizophrenia Episode Project's Early Treatment Program (RAISE-ETP), a nationwide multisite effectiveness study for patients with first-episode schizophrenia spectrum disorders. Treatment with antipsychotics did not exceed 6 months at study entry.
The authors identified 159 patients (39.4% of the sample) who might benefit from changes in their psychotropic prescriptions. Of these, 8.8% received prescriptions for recommended antipsychotics at higher than recommended dosages; 32.1% received prescriptions for olanzapine (often at high dosages), 23.3% for more than one antipsychotic, 36.5% for an antipsychotic and also an antidepressant without a clear indication, 10.1% for psychotropic medications without an antipsychotic, and 1.2% for stimulants. Multivariate analysis showed evidence for sex, age, and insurance status effects on prescription practices. Racial and ethnic effects consistent with effects reported in previous studies of multiepisode patients were found in univariate analyses. Despite some regional variations in prescription practices, no region consistently had different practices from the others. Diagnosis had limited and inconsistent effects.
Besides prescriber education, policy makers may need to consider not only patient factors but also service delivery factors in efforts to improve prescription practices for first-episode schizophrenia patients.
Full-text · Article · Mar 2015 · American Journal of Psychiatry