Psychosocial Treatments to Improve Community Functioning in Schizophrenia: Results of a Cluster-Randomized Comparative Effectiveness Trial
Russell K. Schutt (1,2), Matthew Killam (1), Diane K. Beckman (1,6), Raquelle I. Mesholam-Gately (1,2), Shaun Eack (3), Kim Mueser (4), Sarah Pratt (5), Meghan Santos (5), Jonathan Delman (7), Laura R. Golden (1,6), Tracy Reed (1,6), Matcheri S. Keshavan (1,2)
1. Psychosis Research Program, Dept. of Psychiatry, Beth Israel Deaconess Medical Center, Boston, MA
2. Department of Psychiatry, Harvard Medical School, Boston, MA
3. Department of Social Work, University of Pittsburgh, Pittsburgh, PA
4. Sargent College of Rehabilitation, Boston University, Boston, MA
5. Dept. of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, NH
6. Dept. of Sociology, University of Massachusetts Boston, Boston, MA
7. University of Massachusetts Medical School, Worcester, MA
Background: Schizophrenia-spectrum disorders create substantial burdens for individuals, families, communities, and health care systems. Psychopharmacological treatments can lessen psychotic symptoms but do not improve the social and cognitive deficits that most impair community engagement and functional recovery. With funding from the Patient-Centered Outcomes Research Institute (PCORI), we compared the effectiveness of two evidence-based psychosocial interventions to improve social and community functioning among those with schizophrenia-spectrum disorders and tested age and baseline cognitive functioning as moderators of treatment effects.
Methods: We randomized 15 treatment sites to deliver Cognitive Enhancement Therapy (CET) or Helping Ourselves Pursue and Experience Success (HOPES, a form of social skills training) for one year in weekly sessions led by two clinicians. CET also included weekly cognitive remediation sessions and progress reviews, while HOPES also included a monthly meeting with a clinician and a Community Support Person. Sites recruited 186 adults with schizophrenia or schizoaffective disorder. Project staff conducted remote assessments at baseline, 6 and 12 months, and 18 months (post-treatment) and 24 months (some sites). Primary outcomes: quality of life, social adjustment, social functioning. Secondary outcomes: neurocognitive functioning, social cognition. Symptoms: Positive and Negative Symptom Scale (PANSS-6). Process measures: attendance, retention, satisfaction, other services used. Qualitative interviews about treatment experience with randomly selected clients.
Results: Functioning improved on multiple primary and secondary outcome measures, with some different CET and HOPES treatment effects. Qualitative interviews indicated positive treatment experiences. Attendance, retention, and satisfaction were high. Treating clinicians found the treatment valuable and many hoped to continue providing it.
Conclusions: Cognitive, symptomatic, and functional gains indicate the value of both treatments, while some selective benefits of CET and HOPES suggest clients should be matched with the best treatment for them. Successful project implementation indicates the potential for more adoption in community settings.