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ICOSR 2017: Behavioral Risk Factors and Interventions

18 Apr 2017

As part of our ongoing coverage of the 2017 International Congress on Schizophrenia Research (ICOSR), held March 25-28 in San Diego, we bring you session summaries from some of the participants in the Young Investigator program. We are, as always, grateful for the gracious assistance of YI program directors Laura Rowland and Scott Sponheim, as well as Michelle Tidwell of the ICOSR staff. For this report, we thank Stefania Tognin of the Institute of Psychiatry in London.

On Sunday afternoon, March 26, at the 2017 International Congress on Schizophrenia Research in San Diego, Eoin Killackey from the University of Melbourne in Australia opened the oral session on Behavioral Interventions by presenting the results of a randomized controlled trial (RCT) in which he and his colleagues compared a six-month Individual Placement and Support (IPS) intervention, with a focus on employment and education outcomes, to treatment as usual (TAU) in individuals with a first episode of psychosis. Killackey pointed out that, traditionally, supporting people with psychosis in finding an occupation or in re-engaging with education was not considered a primary goal of mental health services. This is surprising given that young individuals in the early stages of psychosis often want help with education and employment more than they want help with their mental health.

The results of this RCT revealed that compared to TAU, IPS is more effective in promoting employment and engagement with education at six-month follow-up. However, this positive association was lost at the 18-month follow-up. Killackey concluded by stating that although the results are promising at six-month follow-up (end of IPS intervention), the IPS intervention might have a larger and sustained effect if implemented for at least nine to 12 months.

In the second talk, Irwin Rosenfarb from the University of California, San Diego, presented the results from a treatment comparison study in individuals with schizophrenia. Rosenfarb highlighted that skills training programs such Functional Adaptation Skills Training (FAST) are among the most efficacious psychosocial interventions for schizophrenia; however, they show short-term effectiveness. One of the possible reasons for this is that there might be environmental barriers or lack of reinforcement during the intervention. The aim of the presented study was therefore to test the value of adding to FAST a new form of intervention known as Improving Recovery in Schizophrenia (IRIS). Results indicated that IRIS members improved significantly more than FAST members from baseline to follow-up on several measures, including social self-efficacy, control beliefs, and symptom severity. The overall data suggested that the IRIS intervention may enhance the efficacy of FAST and that caretaker assistance, environmental reinforcements, and self-efficacy play important roles in behavior change among individuals with schizophrenia.

Jared Greenberg from the VA Greater Los Angeles Healthcare System presented a study on resilience in homeless veterans with and without a history of psychosis. He started by mentioning that there are several definitions of resilience but that generally it indicates “the ability to recover from illness or adversity.” The study aimed to compare levels of resilience in the homeless, with and without psychosis, by using the Connor-Davidson Resilience Scale (CD-RISC). The results showed that levels of psychological resilience are not significantly different in veterans with and without psychosis. Among homeless veterans with psychosis, greater resilience is associated with lower negative symptoms and greater levels of functioning. He concluded that further studies are needed to determine whether resilience predicts improved outcomes in this homeless population.

In the next talk, Jason Holden from the Veterans Medical Research Foundation in San Diego presented a study investigating provider, team, and leadership characteristics that are associated with the delivery and fidelity of an intervention combining cognitive behavioral therapy (CBT) and social skills training (SST) implemented in assertive community treatment teams (ACT), jointly termed cognitive-behavioral social skills training (CBSST). The results, in brief, showed that the percentage of provider time spent on administrative duties was inversely associated with both number of sessions delivered and fidelity. In addition, providers who delivered more sessions achieved significantly greater fidelity. Interestingly, a trend was found suggesting providers with more confidence and positive attitudes toward CBSST achieved greater fidelity. Holden concluded by suggesting that future evidence-based practices (EBP) implementation strategies should focus on bolstering provider confidence, positive EBP attitudes, and coaching leadership to facilitate an organizational climate on teams that is more responsive and less resistant, which in turn may facilitate greater EBP delivery and fidelity.

Turning to a different topic, Felice Reddy from the University of California, Los Angeles, presented a case-control study on the cognitive costs of social exclusion in schizophrenia. Reddy started by stating that although social exclusion is very common in patients with schizophrenia, surprisingly little work has been done on its impact on cognition and affect. The task chosen to investigate social exclusion is the extensively validated Cyberball task. This was preceded and followed by cognitive tests that included working memory and processing speed tasks.

The results showed that patients with schizophrenia and healthy controls presented with different patterns in neurocognitive performance following social exclusion. Patients with schizophrenia became worse after being excluded and were less able to perform tasks requiring working memory and processing speed, while the healthy controls’ performance improved after they were socially excluded. Results also indicate that patients had significantly higher levels of defeatist beliefs than controls, and both groups showed a significant increase in defeatist beliefs after social exclusion compared to inclusion. Reddy concluded by stating that these data support the notion that social and environmental factors may contribute to impaired neurocognitive functioning in schizophrenia.

Returning to the theme of treatment strategies, Daniel Mueller from the Volker Roder University Hospital of Psychiatry and Psychotherapy in Bern, Switzerland, presented the results of a cognitive remediation therapy (CRT) intervention on relapse prevention in a schizophrenia outpatient sample. The CRT approach implemented was the Integrated Neurocognitive Therapy (INT) developed by the authors. Results at one-year follow-up showed that 76 percent of the patients in the INT group and 46 percent in the TAU group did not relapse. In addition, compared to TAU, INT was significantly associated with improvements in negative symptoms and psychosocial functioning, and in the cognitive domains of speed, executive functioning, and emotion processing.

In his presentation, Joseph Ventura from UCLA set the scene by explaining why negative symptoms are important in schizophrenia. He then presented results from an RCT that tested the hypothesis that combined cognitive training and aerobic exercise would improve symptoms and social functioning in first-episode schizophrenia patients. The preliminary findings supported the use of aerobic exercise to enhance the effects of cognitive training for reducing negative symptoms and improving social functioning.

Andrea Auther from Zucker Hillside Hospital in New York then presented a study on the implications of social skill deficits as a developmental trait in psychosis by examining change in social functioning in a sample of individuals at clinical high risk of developing psychosis. The results indicated that individuals at clinical high risk of psychosis who present with a decline in social functioning are at greatest risk for developing psychosis. In contrast, individuals at clinical high risk who improve over time are likely not to be at risk for either psychosis or functional disability. The remaining individuals displaying stable poor functioning seem to be less likely to develop psychosis, but they are at higher risk for long-term functional disability.

Finally, Eva Velthorst from Mount Sinai University in New York highlighted that despite the importance of impaired social functioning in the pathway to psychosis, there is no clear understanding of the etiological underpinnings of this relationship. She presented a study that used a large sample of young individuals (N = 2,257, age 14-18) and combined imaging, clinical, and genomewide association data to dissect how early disruptions in social functioning are related to psychotic experiences. The results supported the hypothesis that social impairment is an independent contributor to psychosis risk. In particular, the results suggested that early social impairment and high polygenic risk are two independent pathways to psychotic experiences.