Toronto, October 4, 2016 - A modified version of a successful treatment is improving the day-to-day lives of people with schizophrenia, and its shorter, more sustainable approach could make the beneficial treatment available to more people.
A team from the CAMH and the University of Texas collaborated to develop and test a modified form of cognitive adaptation training (CAT), an intensive treatment that addresses the aspects of schizophrenia that are typically not well addressed with standard treatments: the cognitive impacts (including memory and attention) and the basic, in-home supports and activities that are essential to moving forward in areas such as employment, social and leisure activities.
Based on a pilot study, a shorter course of CAT complemented by less intensive followup not only delivers the same benefits for people with schizophrenia, but is successful at helping them sustain their gains over the long term, as published in 2014 in the journal Schizophrenia Research.
Now, the CAMH team is testing the modified CAT model in a randomized controlled trial as the next stage of their research into how to make further gains for people with this mental illness. This time, the focus is on a younger, early-intervention group of clients, and the initiative is being supported jointly by the Slaight Family Centre for Youth in Transition and the Complex Mental Illness Program at CAMH.
"The way people usually understand schizophrenia is that it is about hallucinations and delusions, and that's often the focus of treatment and medications," says Dr. Sean Kidd, Clinician Scientist in the Complex Mental Illness Program and Interim Psychologist in Chief at CAMH. "In fact, far greater challenges can happen due to cognitive difficulties in areas such as memory and attention, and the negative symptoms of schizophrenia: losing your momentum and drive, keeping organized. There's often very little to offer for these very pressing concerns."
Dr. Sean Kidd
That's where cognitive adaptation training, a treatment created and first implemented by Dr. Dawn Velligan of the University of Texas, comes in. CAMH implemented CAT as a treatment in 2011. "It's about helping people engage with life again," says Dr. Kidd. This treatment pairs a CAT clinician and an individual with schizophrenia to work toward goals defined by the individual, such as organizing their home or getting out in the community. The two meet in the client's home or a community setting for an hour or longer each week over a nine-month period, and the clinician provides strategies and easy-to-use tools. "We build on their independence with any recovery area they're working on, such as employment, volunteerism, organization or socialization," explains Raquel Williams, Occupational Therapist in CAMH's Complex Mental Illness Program.
It's a proven, successful approach with "phenomenal outcomes,” says Dr. Kidd. But research into U.S. outcomes by the University of Texas found that the gains that individuals made over the nine-month treatment were not sustained after the treatment ended. As health-care providers face increasing fiscal pressures, delivering the greatest benefits for clients in the most sustainable way is another challenge.
CAT clinicians and Occupational Therapists Raquel Williams and Joy-Ann Perry
The idea for a modified version of CAT sparked when Dr. Kidd met with Dr. Velligan of the University of Texas, who raised the issue of declining gains among clients.
The modified model shortens the nine-month program to four months of intensive cognitive adaptation training, supported by five months of followup care provided by the client's case manager, who received CAT training. To support the transition, the CAT clinician prepares a written report and meets with the client and the case worker to review next steps at the handover point, as well as one month later. The CAT clinician is available throughout to consult with the case manager. The case manager meets with the client at the individual's home or in the community one or two visits per month, as well as by phone or in a clinic as needed.
The research team piloted the modified CAT model with 24 patients over 18 months. In all three assessment measures, "there was evidence of functional improvement at a level that is comparable to previous trials" of the nine-month program, and "functional gains were sustained" at the end of the five months of case manager follow-up, as published in Schizophrenia Research. “We observed truly remarkable improvements in the lives of people with some of the most challenging forms of the illness,” says Dr. Kidd. “Our team meetings became the highlight of the week for everyone involved – hearing about major accomplishments achieved in a relatively short period of time by the people we worked with.” The team has since developed formal training sessions to prepare other healthcare practitioners in using the modified CAT model, and more than 65 CAMH and external clinicians have completed training over the past two years.
A reminder sign around the home is one example of
supports used in cognitive adaptation training to help people
experiencing memory problems with schizophrenia.
To study this modified approach in a rigorous test, the researchers are conducting a randomized controlled trial with two phases. This work is being done in collaboration with Dr. Chris Bowie, a leading cognitive remediation researcher and Clinician-Scientist in CAMH’s Campbell Family Mental Health Research Institute. The research is focusing on youth and young adults up to age 34.
The first phase kicked off in the summer of 2015, comparing the modified CAT model and a group-based treatment called action-based cognitive remediation – an approach geared more to improving cognitive ability levels through practising cognitive tasks. Forty-eight participants took part in the trial.
As the team began the study, “our hope was that both interventions would work and support clients in being more successful in achieving their recovery goals," says Williams, who works as part of the CAMH treatment and research team studying both approaches. If the modified CAT treatment continues to show successful results in this trial, this would reinforce the benefits of using this more sustainable approach to help a greater number of people as they cope with schizophrenia in their daily functioning. Based on preliminary results, “outcomes for both treatments appear to be very promising,” says Dr. Kidd.
Now, the researchers are kicking off the trial’s second phase. While CAT and cognitive remediation are often presented as a dichotomy, "the most interesting idea is tying them together," says Dr. Kidd. In this arm of the study, participants are randomly assigned to CAT or a combined CAT-cognitive remediation intervention. Both interventions are outreach or community-based approaches. This second phase of the trial will continue into the spring, and will be among the most intensive explorations of such a combined intervention to date.
This is an updated version of an article that first appeared in the Summer 2015 issue of CAMH Discovers.
See more CAMH stories, tools and videos for Mental Illness Awareness Week 2016.