Modified approach, better results for people with schizophrenia
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 Centre for Addiction and Mental Health (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 symptoms of schizophrenia that are frequently neglected but often the most debilitating: executive functioning (such as planning, reasoning and problem-solving), motivation and impulsivity.
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.
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.
"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 very little attention to these very pressing concerns."
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.
A reconceived approach
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 last year in the journal 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 is now training more clinicians in CAMH's Complex Mental Illness program to use the modified CAT model.
To study this modified approach in a rigorous test, the researchers are conducting a randomized controlled trial 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. This work is being supported jointly by the Complex Mental Illness Program and the Slaight Family Centre for Youth in Transition at CAMH, and is being done in collaboration with Dr. Chris Bowie, a leading cognitive remediation researcher from Queen’s University. This time, the research is focusing on youth and young adults up to age 34. The research team began treating individuals as part of the trial in June, with a target to complete the study by the end of the year.
"We hope both interventions will 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.
And the CAMH researchers are looking ahead to other ideas. While CAT and cognitive remediation are often presented as a dichotomy, "the most interesting idea is tying them together," says Dr. Kidd. It's the next research area on the team's horizon.