Schizophrenia Symptoms, Hospitalizations Reduced With Psychological Rehabilitation

(Part 2 of 3)

Watch Leslie Citrome, MD, MPH, clinical professor of psychiatry and behavioral sciences at New York Medical College, Valhalla, New York, discuss the severity of functional deficits in schizophrenia and the importance of psychological rehabilitation, such as cognitive remediation and vocational rehabilitation.

In the previous part 1, Dr Citrome breaks down the regions of the brain responsible for symptoms and tools for assessing cognition and reviews the Personal and Social Performance Scale (PSP) and the MATRICS Consensus Cognitive Battery (MCCB).

In the upcoming 3, Dr Citrome examines neurobiological targets, the current research regarding antipsychotics, and other schizophrenia treatment options.

Read the transcript:

Let's take a look at the severity of functional deficits in schizophrenia, and let's get a sense of how common they are. Only 10 percent of all patients with schizophrenia work full-time. Only one-third ever worked part-time.

Fewer than 10 percent of male patients with schizophrenia have a child, and the self-care deficit is reflected in high rates of medical comorbidity. This is a problem. Functional deficits are a problem.

Employment in schizophrenia, let's take a closer look. Very few patients are employed full-time. Most patients are unemployed. In terms of full-time employment, rough estimate, about 10 percent. Part-time, unsupported employment, about another 10 percent. Part-time support, 22 percent, 20 percent, I would say. Unemployed, close to 60 percent.

There are some things we can do about all this. Some are psychosocial approaches or cognitive approaches. You have heard about cognitive behavioral therapy. Possibly, you've heard about cognitive remediation.

Cognitive behavioral therapy or CBT, although it's labor-intensive, can be helpful, even in patients considered treatment refractory, and has been evaluated in controlled clinical trials in patients with treatment-resistant schizophrenia.

Cognitive remediation is a very specific type of treatment. It's a set of drills or interventions designed to enhance cognitive functioning. It's a therapy that engages the patient in learning activities that enhance neurocognitive skills relevant to their chosen recovery goals. It's very personalized.

Moderate range effect sizes on cognitive test performance and daily functioning have been reported in several meta-analyses of cognitive remediation. Now, psychosocial rehabilitation is an umbrella term that includes efforts to improve neurocognition.

Those areas of cognition that I mentioned before, attention, processing, memory, reasoning, verbal learning, visual learning, as well as social cognition. That's emotional processing, social perception, attributional bias, what patients attribute one feeling to another, motivation.

Ultimately, psychosocial rehabilitation includes improving functional and subjective outcomes. It's the whole package. What it consists of is a range of techniques that are used, including CBT and cognition remediation, as well as addressing patient employment.

We talked about how common it is for patients to not be working. One of the key goals in psychosocial rehabilitation is helping patients live independently and be employed. Employment is identified as a goal for most of our patients. They'll tell us on many occasions, "Yes, I'd like to have a job."

Let's talk about vocational rehabilitation now and support employment. There are several barriers to employment. These include, of course, the cognitive impairments we've talked about, the psychiatric symptoms. Perhaps substance use, non-psychiatric medical condition, stigma from employers, internalized stigma and low self-confidence, and the fear of losing disability benefits.

What can we do? Vocational rehabilitation addresses these barriers by providing skill training, sheltered workshops, transitional employment, and supported employment, as well as the maintenance of benefits. That's really important.

The last thing our patients need is to lose, for example, their Medicaid benefits. Basic principles of supported employment are zero exclusion. Everyone could participate with eligibility based on consumer choice.

Focus on competitive jobs and integrated community settings, rapid job searches, respect for the consumer's preferences in terms of the nature of the job and type of support services, ongoing job support, close integration with a psychosocial rehabilitation team, and benefits counseling.

I can't underestimate the importance of benefits counseling. This may include managing a disability benefit and not losing it, social security, and of course, medical insurance.

In a randomized control trial evaluating the effects of adding cognitive remediation to a vocational rehabilitation program, compared with the vocational rehabilitation alone, in 34 people with severe mental illness, you might be surprised at the outcome.

Patients who received both cognitive remediation and vocational rehabilitation demonstrated significantly greater improvements on a cognitive battery over three months than those who received vocational rehab alone and had better work outcomes over the two-year follow-up period.

A comprehensive approach is better, and for those community settings that can offer this, their patients are better off. With employment, one may expect increased self-esteem, reduction in symptoms and hospitalizations, enhanced social functioning, and improvement in overall quality of life.

Leslie Citrome, MD, MPH, is Clinical Professor of Psychiatry and Behavioral Sciences at New York Medical College in Valhalla, New York, and has a private practice in Pomona, New York. He graduated from the McGill University Faculty of Medicine in Montreal, Canada and completed a Residency and Chief Residency in Psychiatry at the New York University School of Medicine. He also went on to complete a Masters in Public Health at Columbia University. 

Dr Citrome was the founding Director of the Clinical Research and Evaluation Facility at the Nathan S. Kline Institute for Psychiatric Research in Orangeburg, New York. After nearly 2 decades of government service, as a researcher in the psychopharmacological treatment of severe mental disorders, Dr. Citrome is now engaged as a consultant in clinical trial design and interpretation. He is a frequent lecturer on the quantitative assessment of clinical trial results using the metrics of evidence-based medicine. He is a member of the Board of Directors of the American Society of Clinical Psychopharmacology. 

Dr Citrome is the editor-in-chief of the International Journal of Clinical Practice. He has authored or co-authored over 500 published research reports, reviews, and book chapters within the biomedical literature. He is the author of the textbook, Handbook of Treatment-Resistant Schizophrenia, published in 2013 by Springer Healthcare.