Integrating Recovery-Oriented Cognitive Therapy Into Medication Management Visits: Feasibility and Acceptability.

Chapter 18 - Promoting Psychosocial Functioning and Recovery in Schizophrenia Spectrum and Other Psychotic Disorders

BackgroundSocial functioning, symptoms, cognition and well-being are all considered important recovery domains for patients with schizophrenia spectrum disorders (SSD). In the current study, we investigated to what extent longitudinal changes in one recovery domain moderated changes in another recovery domain, and which personal, clinical or social patient characteristics influence changes in recovery domains for patients with SSD.MethodsWe investigated data from GROUP, a prospective, longitudinal six-year study of patients with SSD. We analyzed longitudinal changes in 15 outcomes (i.e., subdomains of symptoms, social functioning, cognition, quality of life or well-being), through a linear mixed-effects model analysis. Changes in other outcomes, patients’ duration of illness (DOI), and personal, clinical, or social patient characteristics at baseline were treated as covariates in the analyses.ResultsWe observed long-term improvement in all outcomes, except for depressive symptoms and subjective well-being. Larger improvements in positive symptoms, social functioning and executive functioning were indicated for patients with a short DOI. We found multiple, moderating effects, mainly for patients with a short DOI, between changes in cognition, social functioning, symptoms and quality of life. Limited moderating effects were indicated between these recovery domains and well-being. Baseline levels of outcomes, schizophrenia diagnosis, education level, ethnicity, living situation, employment status and marital status were all moderators for changes in most outcomes.ConclusionsSymptoms, social functioning, cognition and quality of life often concurrently improved over the course of SSD. These longitudinal changes were mostly driven by social patient characteristics, such as education level, ethnicity, living situation, employment status and marital status.Clinical trial numberNot applicable.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12888-025-07700-8.

The aim of this study was to investigate the feasibility of adapting group-based interpersonal psychotherapy (IPT-G) for patients with chronic post traumatic stress disorder (PTSD). Thirteen subjects with DSM-IV-defined PTSD, with symptom duration greater than 12 months, entered the study, an 8-week treatment programme conducted in a clinical setting using IPT-G modified for the treatment of PTSD. Data obtained were analysed qualitatively and quantitatively. All 13 subjects completed the treatment programme and showed significant improvement in social functioning, general wellbeing and depressive symptoms. Treatment completers demonstrated a moderate reduction in the avoidant symptom cluster of PTSD. These improvements appeared stable at 3-month follow-up. Benefits appeared to be associated with perceived intra-therapy progress in resolving identified IPT problem areas. Qualitative analysis found that themes of 'reconnection' and 'interpersonal efficacy' were core parts of the experience of the treatment. IPT-G modified for PTSD appears to be of modest symptomatic benefit, but may lead to improvement in social functioning, general psychological wellbeing and enhanced interpersonal functioning. Further studies are indicated.

Social cognition in patients with schizophrenia spectrum and bipolar disorders with and without psychotic features

Reduced social impairment and improved life satisfaction are important objectives in group treatment for patients with personality dysfunction. Knowledge regarding patient characteristics and group treatment processes that contribute to these outcomes, however, remains limited. Dispositional connectedness, the valuing of interpersonal connections, may be an important patient factor that influences patients' experience of group treatment in ways that facilitate therapeutic benefits. The present study investigated the roles of dispositional connectedness and group engagement in contributing to improvement in social functioning and life satisfaction through integrative group treatment for personality dysfunction. Seventy-nine patients who completed an integrative group treatment programme were assessed for dispositional connectedness at baseline and social functioning and life satisfaction at pretreatment and posttreatment; each also provided ratings of group engagement during treatment. Regression analyses using bootstrap confidence intervals found significant indirect effects for dispositional connectedness regarding improvement in both social functioning and life satisfaction, through the mediating effect of group engagement. Thus, patients who entered treatment with tendencies towards interpersonal connectedness perceived a higher level of engagement in the group environment. Group engagement in turn contributed to greater improvement in social functioning and to greater improvement in life satisfaction following treatment. The findings indicate dispositional connectedness as a salient characteristic in selecting patients for group treatment and highlight the role of an engaged interpersonal climate in facilitating improvement in social functioning and life satisfaction.

Benefits of social cognitive skills training within routine community mental health services: Evidence from a non-randomized parallel controlled study.

BackgroundCognitive problems in people with schizophrenia predict poor functional recovery even with the best possible rehabilitation opportunities and optimal medication. A psychological treatment known as cognitive remediation therapy (CRT) aims to improve cognition in neuropsychiatric disorders, with the ultimate goal of improving functional recovery. Studies suggest that intervening early in the course of the disorder will have the most benefit, so this study will be based in early intervention services, which treat individuals in the first few years following the onset of the disorder. The overall aim is to investigate different methods of CRT.MethodsThis is a multicentre, randomised, single-blinded, controlled trial based in early intervention services in National Health Service Mental Health Trusts in six English research sites. Three different methods of providing CRT (intensive, group, and independent) will be compared with treatment as usual. We will recruit 720 service users aged between 16 and 45 over 3 years who have a research diagnosis of non-affective psychosis and will be at least 3 months from the onset of the first episode of psychosis. The primary outcome measure will be the degree to which participants have achieved their stated goals using the Goal Attainment Scale. Secondary outcome measures will include improvements in cognitive function, social function, self-esteem, and clinical symptoms.DiscussionIt has already been established that cognitive remediation improves cognitive function in people with schizophrenia. Successful implementation in mental health services has the potential to change the recovery trajectory of individuals with schizophrenia-spectrum disorders. However, the best mode of implementation, in terms of efficacy, service user and team preference, and cost-effectiveness is still unclear. The CIRCuiTS trial will provide guidance for a large-scale roll-out of CRT to mental health services where cognitive difficulties impact recovery and resilience.Trial registrationISRCTN, ISRCTN14678860, Registered on 6 June 2016.

Cognitive impairments contribute to difficulty in obtaining employment for people with severe mental illnesses (SMIs). We describe a pilot evaluation of a programme, Employ Your Mind (EYM), which integrates cognitive remediation therapy (CRT) with vocational rehabilitation. Sixty participants with SMIs enrolled in EYM, a 6-month programme that combines CRT exercises, individual project work and group reflection sessions about social interaction and cognitive functioning. Participants completed assessments of cognitive function (Audio Recorded Cognitive Screen, Wechsler Digit Span Task), psychosocial function (Work and Social Adjustment Scale, General Self-Efficacy Scale) and abilities related to work (Dialogue about Working Ability, Self-Assessment of Thinking Skills) at baseline and postprogramme. Paired t-tests were used to compare assessments of participants who completed the programme between the two time points. The programme was completed by 22 individuals. These individuals demonstrated significant improvement in cognitive function, social and work-related function, and subjective thinking ability after completing the EYM programme. The EYM programme is effective in improving cognition, impairments related to work and social function, and subjective thinking skills for some individuals with SMIs. Future evaluation of the programme should focus on enhanced retention and assessment of employment outcomes.

Do cognitive impairments limit treatment gains in a standalone digital intervention for psychosis? A test of the digital divide

Heterogeneity in Schizophrenia Spectrum Disorders: Studies on Functional, Affective, and Metabolic Outcomes This dissertation aimed to explore the heterogeneity in schizophrenia spectrum disorders (SSD) by examining long-term clinical and subjective outcomes in older adults and by investigating the role of depressive symptomatology in relation to metabolic risk. Part 1: Long-term Course of Remission and Quality of Life in Older Adults with SSD With an aging population, the number of older individuals with SSD is increasing. Their care needs often differ from those of younger patients. A better understanding of the long-term course of SSD in later life is therefore essential. Contrary to earlier beliefs that schizophrenia inevitably leads to a dementia-like state, more recent evidence suggests a more diverse and sometimes favorable course in older patients. Symptomatic remission, defined as a state of low symptom severity, has become a useful clinical concept. However, recovery must also include the patient’s perspective, especially in terms of subjective quality of life (SQoL). Using data from the SOUL study, we analyzed 77 patients aged 60+ over a 5-year period. We found that 26% of patients improved in terms of symptomatic remission, while 23% remained stable in remission. Key predictors of a favorable course were lower baseline positive symptoms and having a partner. In a separate analysis of 75 patients from the same cohort, we examined changes in SQoL using the Manchester Short Assessment of Quality of Life (MANSA). About 36% showed clinically relevant improvement, while 20% experienced a decline. Factor analysis revealed three SQoL domains: ‘personal circumstances,’ ‘daily life,’ and ‘social relations,’ with the first two showing notable improvement. Older age predicted more change, whereas a higher baseline SQoL score predicted stability. These findings suggest that improvement in both clinical and subjective outcomes is achievable even at later ages. Part 2: Depressive Symptom Profiles and Metabolic Syndrome in SSD People with SSD have higher mortality rates and shorter life expectancy, partly due to somatic conditions like cardiovascular disease, obesity, and diabetes. Recent studies suggest a link between depressive symptoms and metabolic syndrome (MetS), especially symptoms related to energy dysregulation. We compared depressive symptom profiles in 449 individuals with SSD, 816 with depressive disorders (DD), and 417 healthy controls (aged 18–50). Somatic/vegetative symptoms were more similar between SSD and DD groups than cognitive/mood symptoms. Among SSD patients, depressive symptom severity was associated with male gender, lower social functioning, use of benzodiazepines, and higher positive symptom burden. In a second study of 513 individuals with SSD, we examined the relationship between energy-related depressive symptoms (e.g., hypersomnia, hyperphagia, fatigue) and MetS. A third of the sample met criteria for MetS. Energy-related symptoms—but not melancholic symptoms—were significantly associated with both the presence and severity of MetS. Notably, hypersomnia showed the strongest link. Conclusion This dissertation underscores the heterogeneity in SSD, both in long-term outcomes and comorbid conditions. Older individuals with SSD can experience improvements in remission and quality of life, especially with social support. Additionally, specific depressive symptom patterns—particularly energy-related symptoms—may help identify patients at greater metabolic risk, supporting the need for integrated care approaches that address both mental and physical health.

Cognitive impairment after critical illness is common and debilitating. We developed a cognitive therapy program for critically ill patients and assessed the feasibility and safety of administering combined cognitive and physical therapy early during a critical illness. We randomized 87 medical and surgical ICU patients with respiratory failure and/or shock in a 1:1:2 manner to three groups: usual care, early once-daily physical therapy, or early once-daily physical therapy plus a novel, progressive, twice-daily cognitive therapy protocol. Cognitive therapy included orientation, memory, attention, and problem-solving exercises, and other activities. We assessed feasibility outcomes of the early cognitive plus physical therapy intervention. At 3 months, we also assessed cognitive, functional, and health-related quality of life outcomes. Data are presented as median (interquartile range) or frequency (%). Early cognitive therapy was a delivered to 41/43 (95%) of cognitive plus physical therapy patients on 100% (92-100%) of study days beginning 1.0 (1.0-1.0) day following enrollment. Physical therapy was received by 17/22 (77%) of usual care patients, by 21/22 (95%) of physical therapy only patients, and 42/43 (98%) of cognitive plus physical therapy patients on 17% (10-26%), 67% (46-87%), and 75% (59-88%) of study days, respectively. Cognitive, functional, and health-related quality of life outcomes did not differ between groups at 3-month follow-up. This pilot study demonstrates that early rehabilitation can be extended beyond physical therapy to include cognitive therapy. Future work to determine optimal patient selection, intensity of treatment, and benefits of cognitive therapy in the critically ill is needed.

In psychosis, treatment often focuses on symptom reduction whereas social functioning is also essential. In this study, we investigate positive psychotic symptoms and medication use in relation to social functioning over a 3-year time-period in 531 patients diagnosed with psychosis. Furthermore, relations of positive symptoms with needs for care and quality of life were also investigated. Using repeated measures analysis, changes were measured over time. Hereafter, mixed model analyses were performed to determine the associations of social functioning, needs for care, and quality of life with psychotic symptoms and patient characteristics. Finally, we assessed differences in symptoms and medication dose between those with an increase and those with a decrease in social functioning. Patients significantly improved in social functioning, while psychotic symptoms increased. Improvement in social functioning was associated with younger age, higher IQ, and lower social functioning at T1, but not with positive symptoms. Also, improvement in social functioning was found to be related to a decrease in the dose of clozapine. Improvement in social functioning occurs despite worsening of positive symptoms. The findings suggest the need to further explore the relation between symptomatology, social functioning, and medication use. In the treatment of psychotic disorders, one should reconsider the strong focus on reducing psychotic symptoms. The current focus needs to shift much more toward improving functional outcome, especially when the patient expresses a desire for change in this respect.

Community care units (CCUs) are a model of residential psychiatric rehabilitation aiming to improve the independence and community functioning of people with severe and persistent mental illness. This study examined factors predicting improvement in outcomes among CCU consumers. Hierarchical regression using data from a retrospective cohort (N = 501) of all consumers admitted to five CCUs in Queensland, Australia between 2005 and 2014. The primary outcome was changed in mental health and social functioning (Health of the Nation Outcome Scale). Secondary outcomes were disability (Life Skills Profile-16), service use, accommodation instability, and involuntary treatment. Potential predictors covered service, consumer, and treatment characteristics. Group-level and individualised change were assessed between the year pre-admission and post-discharge. Where relevant and available, the reliable and clinically significant (RCS) change was assessed by comparison with a normative sample. Group-level analyses showed statistically significant improvements in mental health and social functioning, and reductions in psychiatry-related bed-days, emergency department (ED) presentations and involuntary treatment. There were no significant changes in disability or accommodation instability. A total of 54.7% of consumers demonstrated reliable improvement in mental health and social functioning, and 43.0% showed RCS improvement. The majority (60.6%) showed a reliable improvement in psychiatry-related bed-use; a minority demonstrated reliable improvement in ED presentations (12.5%). Significant predictors of improvement included variables related to the CCU care (e.g. episode duration), consumer characteristics (e.g. primary diagnosis) and treatment variables (e.g. psychiatry-related bed-days pre-admission). Higher baseline impairment in mental health and social functioning (β = 1.12) and longer episodes of CCU care (β = 1.03) increased the likelihood of RCS improvement in mental health and social functioning. CCU care was followed by reliable improvements in relevant outcomes for many consumers. Consumers with poorer mental health and social functioning, and a longer episode of CCU care were more likely to make RCS improvements in mental health and social functioning.

Background: Cognitive Enhancement Therapy (CET) is an effective treatment to improve social cognition and neurocognition for individuals with schizophrenia (Hogarty & Flesher, 1999). CET is associated with improvement in employment (Eack et al., 2009), functional outcomes (Eack et al., 2011), and reducing negative symptoms (Eack et al, 2013). While CET is linked to these outcomes, research has not investigated client satisfaction and subjective experiences. Our proposed study hopes to address this gap in the literature and evaluate experiences and satisfaction in a diverse community medical center. Methods: The current study utilizes participants (N = 17) engaging in CET. Participants completed a satisfaction survey and semistructured interview to capture satisfaction and subjective experiences. Surveys consist of 13 questions stressing CET components such as satisfaction, coaching, and homework. Survey questions are on a Likert-type scale with 1 being “completely disagree” and 5 being “completely agree”. Semistructured interviews consist of 8 open-ended questions exploring likes/dislikes, accomplishments, and areas of learning. Descriptive statistics of surveys were analyzed and thematic analysis was used to code transcribed interviews. Results: Participants’ mean age was 42.24 (SD = 12.23). All participants were diagnosed with a schizophrenia spectrum disorder (N=17). Participants’ racial/ethnic backgrounds included Caucasian/white (n = 5), African American/black (n = 5), multiracial (n = 4), and Asian/Pacific Islander (n = 3). Results from surveys indicated that CET is worth their time (n = 17, 100%), satisfaction with CET classes is high (M = 4.06), and all CET participants feel comfortable talking with their CET coach (n = 17, 100%). Several themes from interviews emerged. Themes indicated that CET compared to other groups (1) is more difficult, (2) feels more educational, and (3) has more client participation and coach questioning. Interviews also suggested that participants find CET beneficial due to (1) treatment being interactive, (2) promotion of learning communication and social skills, (3) improved attention, and (4) individual coaching and feedback. More details about participant surveys and interviews will be reported. Conclusion: The current study shows preliminary evidence that CET is a unique and satisfactory treatment. Previous research shows that client preferences affect satisfaction, completion, and clinical outcomes (Lindhiem et al., 2014). Thus, more research is needed to measure program satisfaction and experiences to improve outcomes.

The use of modified ride-on cars to maximize mobility and improve socialization-a group design