Computerized Brain Training Can Produce Functional Changes in Schizophrenia

An article posted online on October 31st by Psychiatric News:

Successful training of the brains of people with schizophrenia in discrete attentional tasks is possible and appears to translate into improvements in quality of living, said Sophia Vinogradov, M.D., winner of APA’s Alexander Gralnick Award (pictured with past APA President and current APA American Psychiatric Foundation Treasurer Richard Harding, M.D.) At APA's Institute on Psychiatric Services in San Francisco, Vinogradov described research showing that computerized games aimed at training the brains of patients in very specific tasks can have effects on multiple interactive systems resulting in changes in global functioning. The finding marks a new direction in what has been called “cognitive remediation.” Further coverage of Vinogradov’s remarks will appear in a future issue of Psychiatric News. For further information about cognitive remediation, see "Neurocognitive ‘Training’ May Undo Schizophrenia's Brain Damage" and American Psychiatric Publishing's Essentials of Schizophrenia by Jeffrey Lieberman, M.D.

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Today's Ultrashort Stays Raise Questions About Effectiveness

An article published in the February 4th edition of Psychiatric News:

By Mark Moran

The scant research that exists tends to support shorter-term hospitalization over long term, but in most studies what was once considered short term would be long term today.

Twenty-five years ago when Steven Sharfstein, M.D. (pictured), came to the Sheppard and Enoch Pratt Hospital in Maryland, the average length of stay there was 80 days.

In that time, the patient received a diagnosis and an individualized treatment plan including medication and psychotherapy addressing acute symptoms as well as intrapsychic and psychosocial factors, with the active engagement of family members and the formulation of an aftercare plan. It was a protocol that was not atypical for many other freestanding psychiatric hospitals; at general hospitals, the length of stay was often 20 to 30 days.

But today, the same patient entering almost any hospital in the United States for psychiatric care will likely be out the door in five or six days, in what Sharfstein calls the “ultrashort stay.” Such treatment as can occur in that time focuses on crisis stabilization, relief of the most acute symptoms, and de-escalation of dangerousness.

Between Sharfstein's arrival at Sheppard Pratt in 1986 and today, a perfect storm of factors—managed care, the expansion of insurance coverage for outpatient treatment, and a belief in the efficacy of the least-restrictive therapeutic environment—has reduced psychiatric hospitalization to something that looks less like treatment than a kind of holding action or police function whose purpose is ensuring patient and public safety.

“When I give a talk today, I tell people that hospital treatment is an oxymoron,” Sharfstein said in an interview with Psychiatric News. “We no longer really do treatment. What we do is stabilize, evaluate, and keep the patient as safe as we can.”

In an “Open Forum” essay that appears in the February Psychiatric Services, Ira Glick, M.D., Sharfstein, and Harold Schwartz, M.D., argue that the ultrashort five- to six-day hospital stay may actually subvert the goals of recovery and may contribute to the criminalization of mentally ill individuals by releasing patients to the community with no real recovery-oriented, long-term treatment plan.

The authors offered a model for reform of psychiatric hospitalization that revives the therapeutic function of the hospital and leaves enough time for accurate assessment, real engagement with the patient and family, and formulation of an individualized treatment plan aimed at long-term recovery (see How to Make Hospitalization Useful).

“We don't want a return to long-term hospitalization,” Sharfstein said, “but five or six days is too short. The purpose of the article is to raise the concern that in thinking about health reform, the hospital piece has been left out.

“Hospitalization is an opportunity, not a disaster,” he said. “It's an opportunity to bring high-tech resources to bear on the patient's illness and to come up with a better outpatient plan, one that will help the patient adhere to treatment and be better connected to psychotherapy and psychosocial interventions.”

Where Should Recovery Occur?

Yet the belief that recovery-oriented treatment should happen outside the hospital walls is persistent, and in an editorial accompanying the article, Psychiatric Services Editor Howard Goldman, M.D., Ph.D., argues that the appropriate role of inpatient care in the range of services for mental illness has yet to be resolved.

“Not all patients who need 24-hour supervision or confinement . . . need [hospital-level care],” Goldman wrote. “For some patients, freestanding psychiatric hospitals, affiliated with academic centers, are a more appropriate, lower-cost alternative to the general hospital. For many others, 24-hour alternatives may be more appropriate than the acute care hospital.”

In an interview with Psychiatric News, Marvin Herz, M.D., a longtime advocate for outpatient psychosocial interventions, said that while rigid adherence to a five- to six-day protocol serves no one well, he does not favor an expanded role for inpatient care as outlined by Glick and colleagues.

“I see the hospital as part of a broader system of care that ideally provides a continuum,” Herz told Psychiatric News. “In my opinion the definitive treatment in terms of helping the patient function should be in an ambulatory setting, not in the hospital. [Glick and colleagues] proposed an expanded role for the goals and methods of acute inpatient treatment that will inevitably increase length of stay and costs compared to the current inpatient model of crisis stabilization followed by appropriate ambulatory care.”

Anticipating those arguments, Glick and colleagues argued that lower-cost, low-tech models of care for patients who need 24-hour supervision do not now exist outside the hospital. In the meantime, they wrote, many patients have cognitive problems plus psychotic symptoms that prevent them from being “full partners on the treatment team” and from functioning in an outpatient setting.

Schwartz, psychiatrist in chief at the Institute of Living in Hartford, Conn., emphasized that the intensity of resources that can be brought to bear in an inpatient setting — and the crucial “holding environment” of the hospital — are especially important for influencing the trajectory of illness and recovery following a first-episode psychosis.

“We know that rapid, intense, and early intervention with the most resources possible is critical in the long-term outcome of first-episode psychosis,” he told Psychiatric News. “The evidence is very strong that an inadequately treated first episode predisposes to a second and to a downward trajectory. When we discharge people after five days because they are ‘safe,’ even if they remain psychotic and inadequately prepared for adjustment to life in the community, are we sending these patients on a downward course?”

How Much Hospitalization?

What everyone agrees is that research on the role of hospitalization and the appropriate number of days in a hospital for a given diagnosis is sorely lacking. (Goldman, in his editorial, noted that inpatient research “has disappeared.”)

What research exists tends to favor short-term over longer-term hospitalization. One study published in 1979 in Archives of General Psychiatry by Herz and colleagues looked at 175 newly admitted patients to the Community Service of the New York State Psychiatric Institute. Patients were randomly assigned to standard inpatient care, brief hospitalization followed by the availability of transitional day care, or brief hospitalization.

All patients were offered follow-up outpatient treatment. Initial length of stay was 11 days for both brief-hospitalization groups and 60 days for the standard-care group.

The long-term results indicated little differential effect between treatments, but when differences occurred, they generally favored the brief-care groups, according to the report. Similar results were found in a 1980 British study by Hirsch and colleagues published in the British Journal of Psychiatry.

Glick was principal investigator on studies in the 1970s and 1980s looking at long- and short-term hospitalization for patients with schizophrenia and those with other disorders. Generally, those studies showed that some subgroups of patients benefited from longer hospitalization, but that overall no differences in outcome were detectable when taking into account length of stay and diagnosis.

However, it is noteworthy that in all these studies what was considered “short term” at the time would be a long-term stay today.

“Today, patients admitted to inpatient care are either new cases or chronic patients who get readmitted because they are not complying with treatment,” Glick told Psychiatric News. “What happens with these ultrashort stays is that even the diagnosis is deferred — physicians are reluctant to render a diagnosis so the patient is classified as NOS (not otherwise specified). Then they get a blast of drugs — an antidepressant, antipsychotic, and antianxiety medication — told ‘good luck,’ and get sent out the door.

“What we are arguing for is spending the extra time to make a diagnosis, contact the previous doctor to get a careful history of what has been done or not done in the past, and prescribe an individualized treatment,” Glick said. “As in any other area of medicine, you have to do something active and therapeutic. In the case of psychiatric patients, the treatment team needs to include family, significant others, or a case worker—or it won't work.”

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Patients' Souls Called Medicine's Missing Link

An article published in the December 3rd edition of Psychiatric News:

By Mark Moran

Small changes, beginning with the attitude clinicians bring to a patient encounter, can transform psychiatric and other medical care.

The notion that your patients have a “soul” and that your treatments can touch or transform something less (or more) substantial than a neurotransmitter may sound, in the context of modern biomedical science, quaint today.

But author and psychotherapist Thomas Moore, Ph.D. {pictured], believes the souls of patients in the care of modern medicine are in need of urgent attention. And so too, he says, are the souls of their doctors.

Moore is the bestselling author of The Care of the Soul: A Guide for Cultivating Depth and Sacredness in Everyday Life, the 1992 book that asserted that the greatest poverty in today's technologically triumphant culture is a lack of attention to the soul.

In a new work, Care of the Soul in Medicine, published this year by Hay House Publishers, Moore asserts that this soul-poverty extends to modern medicine.

In an interview with Psychiatric News, Moore said modern medical care has come to be dominated by a highly mechanistic philosophy deriving from the relatively recent 18th century while jettisoning a far more ancient wisdom about care of the soul that dates to the time of classical philosophers.

Much of his new book is focused on care of the soul in general-medical settings, especially in hospitals and in the care of the dying. But Moore said the message of his book should resonate with psychiatrists.

“I understand the field has become more biological,” he said. “My sense is that people entering medicine today get this very intelligent, up-to-date training in biomedical science. And when I talk to psychiatrists about a spiritual approach to healing, it doesn't seem to them to have that intelligence behind it.

“But I would want psychiatrists to know there is a whole world of knowledge and wisdom outside the biological tradition that goes back several thousand years,” Moore said. “They should give a philosophical and spiritual approach to the patients in their care another look, and they may find that it can be very substantive and would complement their biological work.”

Transforming the Medical Setting

But what is the “soul,” and how does one care for it?

The question itself invites speculation that has kept philosophers busy for centuries. But for the purpose of his book and his message to physicians, Moore speaks of the soul as where one cradles the meaning of one's relationships and memories, the sense of mystery about one's own life, and one's understanding of the meaning of illness and death.

To care for the soul in medicine then would be to adopt practices that seek not just the “cure” of disorders, but care for and attention to patients' significant relationships, poignant memories, spiritual quests and interests, as well as their understanding of their illness. Such an approach, he believes, calls for changes in the way doctors are trained and in the way they approach their patients, but it also entails a transformation of the settings in which care is provided to include incorporation of nature, art, and music into the architecture of hospitals and doctors' offices.

His remedies for what ails modern medicine may seem to some either quixotic or “unscientific” (or even “antiscientific”), but his thoughts echo those of such respected thinkers as biomedical ethicist Daniel Callahan, Ph.D., who has written extensively of the need to return to “caring over curing.”

“You don't have to talk too long to patients and their families, as well as doctors and nurses, before they express a common feeling that contemporary medicine, for all its technological virtuosity, lacks something,” he said. “Patients and families will talk about how the medical establishment is just so huge and they feel like a piece of machinery. When I tell them about how images and architecture can transform a healing environment—about how the way a hospital room looks and feels can be a part of healing—they are a little surprised, but they know what I am saying. So I seem to be giving people a language for talking about things they know intuitively.”

Moore is careful not to be critical of physicians — “they get enough criticism,” he said—and noted that after the success of his 1992 book, it was the medical establishment that came to him. As part of his research for the book, he was invited to spend two days each month over a two-year period at St. Francis Hospital in Hartford, Conn.

“When I first wrote Care of the Soul, I didn't have medicine in mind at all,” Moore said. “But I began getting invitations to talk at medical schools, and right up to the present time I have been visiting medical schools, hospitals, and cancer wards all over the country and in Ireland.”

Reclaiming an Ancient Wisdom of the Soul

What does Moore, an admirer of Carl Jung (but he is not, he said, a Jungian), think of the widespread use of pharmacologic agents to treat psychiatric disorders?

“It's a complicated issue, and I have nothing against the use of pharmacologic treatments in conjunction with other approaches,” he said. “But I think it goes hand in hand with the prevailing philosophy of our time that is based on treating people as mechanical systems. If you see the brain as a collection of neurochemicals, you are going to use chemicals to treat people.

“That's the underlying mythology of our time. It is useful as far as it goes, but I think it leaves much to be desired and ignores a vast trove of wisdom about the soul that predates the 20th century.”

His recommendations for reform seem to require changes in a medical system that is itself vast and unwieldy. But Moore believes that even small changes—beginning with the attitude clinicians bring to a patient encounter—can be transformative, even of a 15-minute med check.

“I think psychiatrists would find their work so much more pleasurable and fulfilling if they could reach past the prevalent biological view of a human being and enjoy the complexity of human life,” Moore said. “They could allow themselves to be instructed by the arts, by fiction and drama, painting and music and allow those to inform their practice. It would humanize their work so that they would have a warmer and more fulfilling experience in a context that would be incredibly rich, even if they only had 15 minutes.”

It's not the amount of time spent with a patient that's key, he said. “I can spend 50 minutes with a patient and it seems like nothing. It's where you are coming from that makes the difference.”

Photo courtesy of Thomas Moore, Ph.D.

Shift to Community Care Slowing in Many States

An article published in the August 6th edition of Psychiatric News:

By Rich Daly

Eleven years after the Supreme Court required that community-based treatments be offered to people institutionalized with major health conditions, including serious mental illness, that promise remains unfulfilled and may need legal action to get back on track.

Numerous initiatives by Congress, federal agencies, and mental health advocates have greatly expanded access to community-based treatment for people with serious mental illness in the 11 years since the Supreme Court required such alternatives for qualified people in institutional care. But some observers warn that those efforts are stagnating or even receding.

The Supreme Court's 1999 Olmstead v. L.C. decision declared that “unjustified institutional isolation of persons with disabilities is a form of discrimination” under the Americans With Disabilities Act (ADA) and obligated states to serve those individuals in the most “integrated” setting possible. Since then, mental health advocates have sought to move most people with serious mental illness out of institutional settings and into community treatment where they would have opportunities to work, socialize, and move freely in society.

Those efforts have resulted in community-based treatment and assisted-living programs throughout the country that usually cost states much less than the institutional programs they succeeded, according to Robert Bernstein, president and director of the Bazelon Center for Mental Health Law.

To read the entire article, please click here.

Some With Psychosis Decide Social Life Not Worth It

An article published in the July 2nd edition of Psychiatric News:

By Joan Arehart-Treichel

If people with schizophrenia function poorly in social settings, it may be because they have developed negative beliefs about social functioning, perhaps to protect themselves from rejection.

“Get a life!” people sometimes quip.

“Well, that's not easy to do if you've got schizophrenia,” an individual with this illness might respond.

But it might still be possible. The reason? Negative beliefs about a social life seem to be the major reason why individuals with schizophrenia don't have a social life, a new study has found. And if that is the case, then changing those beliefs might help them “get a life.”

The study was conducted by Paul Grant, Ph.D., a research assistant professor of psychology in psychiatry at the University of Pennsylvania, and Aaron Beck, M.D., [pictured] University Professor Emeritus of Psychiatry at the University of Pennsylvania. Beck is also considered “the father of cognitive therapy.” Results were published in the May 15 Psychiatry Research.

People with schizophrenia tend to isolate themselves from others, yet at the same time they say that they would like to have friends, get a job, and perhaps have a family. What is the explanation for this discrepancy? Could it be negative beliefs and expectations rather than the illness itself? Grant and Beck conducted a study to find out.

The study sample included 123 adults with an average age of 39 who had been diagnosed with schizophrenia or schizoaffective disorder. Various scales were used to evaluate subjects on social functioning, neurocognition, emotion perception, positive symptoms, negative symptoms, depression, anxiety, and negative beliefs about social functioning.

Negative beliefs about a social life were determined with 15 statements from the Revised Social Anhedonia Scale. Several of the statements, for example, were “People are usually better off if they stay aloof from emotional involvement with others,” “Making new friends isn't worth the effort it takes,” and “Having close friends is not as important as most people say.” For each statement, subjects answered yes or no. Subjects' responses were summed into a total score of 0-15, with higher scores indicating more negative beliefs about a social life.

The researchers then used correlational analysis to see whether there were any orderly, predictable relationships between subjects' social functioning scores and their scores on the other measures. None could be found between their social functioning scores and their neurocognition, emotion perception, positive symptoms, and anxiety scores. But such a link could be found between their social functioning scores and their negative symptoms, depression, and scores indicating negative beliefs about the value of a social life.

And most striking, high scores on negative beliefs about a social life were associated with poor social functioning scores.

The researchers then determined the relative contribution to social functioning of neurocognition, emotion perception, negative symptoms, depression, and negative beliefs about social function. They found that neurocognition and emotion perception contributed a negligible amount—a finding that surprised them—but they also found that negative symptoms and depression accounted for somewhat more, and that negative beliefs about a social life accounted for the largest contribution to social functioning.

Finally, they conducted a longitudinal analysis of 13 of the subjects to see whether negative beliefs about social functioning at baseline significantly predicted social withdrawal a year later, or whether social withdrawal at baseline predicted negative beliefs about social function a year later. The former was the case.

Putting all these results together, it looks as if negative beliefs about a social life may be a major reason why people with schizophrenia don't relish social interactions, the researchers concluded. “We propose that the patients' asocial beliefs trump their need for social acceptance,” they wrote.

And, if that is the case, would certain interventions help individuals with schizophrenia change such beliefs and thus improve their social lives? The researchers think that they might.

For example, “encouraging the patient to engage in social contact can expose the dysfunctional beliefs, which can then be the target for cognitive restructuring. Various behavioral techniques such as social-skills training and assertiveness training can facilitate social engagement and demonstrate to the patient the positive consequences of social engagement.... Modifying beliefs that maintain depression, which is also linked to poor social functioning, can further motivate the patient to socialize productively.”

The study was funded by the Foundation for Cognitive Therapy and Research, NARSAD, and the Heinz Foundation.

Also see:

Asocial beliefs as predictors of asocial behavior in schizophrenia


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Recidivism Drops in Those Supervised by Mental Health Courts

An article published in the June 18th edition of Psychiatric News:

By Aaron Levin

Research on the outcomes of mental health courts is steadily accumulating, and the results show promise, but some critical questions remain unanswered.

Criminal defendants who complete programs supervised by mental health courts are less likely to be rearrested in the following two years, according to a new study by North Carolina researchers appearing in the May Psychiatric Services.

About 72 percent of those who completed the program were not rearrested in that time, compared with just 19 percent of those who were expelled from the program and 37 percent of those who chose to leave, said Virginia Hiday, Ph.D., a distinguished professor of sociology and anthropology, and doctoral student Bradley Ray, M.A., both at North Carolina State University.

To read the entire article, please click here.

Also see:

Nova Scotia's Mental Health Court Program

Schizophrenia Patients Show High Rates of Comorbid Illness

An article published in the September 18th edition of Psychiatric News:

By Mark Moran

Metabolic conditions were common but so were such medical conditions as epilepsy and viral hepatitis.

Hospital discharge records of people with a primary diagnosis of schizophrenia showed higher proportions of all comorbid psychiatric conditions and of several general medical conditions than did those of people who did not have schizophrenia.

The general medical conditions included acquired hypothyroidism, obesity, epilepsy, viral hepatitis, type 2 diabetes, essential hypertension, various chronic obstructive pulmonary diseases, and contact dermatitis and other forms of eczema, according to data from the National Hospital Discharge Survey reported in the August Psychiatric Services by researchers in the Department of Epidemiology at Walter Reed Army Institute of Research.

The survey data confirm what has been reported before: that patients with schizophrenia have higher rates of morbidity associated with some general medical conditions.

However, the study authors pointed out that virtually all existing studies of comorbid disorders in schizophrenia test hypotheses and have focused on a single comorbid condition in relatively small and nonrepresentative samples. The current study appears to be the first systematic analysis of comorbidity in general with schizophrenia in the U.S. hospitalized population.

"Our study is hypothesis-generating rather than hypothesis-testing, with the main purpose of presenting a systematic review of comorbid conditions," said coauthor Natalya Weber, M.D., M.P.H. "Psychiatrists can see in this very large and representative sample what conditions are more frequently comorbid with a primary diagnosis of schizophrenia compared to any other primary diagnosis among the U.S. hospital discharges."

Weber is health science administrator in the Division of Preventive Medicine at Walter Reed Army Institute of Research.

To read the entire article, please click here.

Canada's Health System Draws Mixed Reviews From Psychiatrists

Although Canadian psychiatrists generally express satisfaction with their government-run health insurance program, not all are happy with the impact of the government's control over hospitals and medical education.

To read this entire article, written by Joan Arehart-Treichel and published in the May 2nd edition of Psychiatric News, click here.

Also see:

A Tale of Two Medicares

Image courtesy of Psychiatric News.

Genetic Link to Schizophrenia Discovered

From National Public Radio:

All Things Considered, March 27, 2008 · Researchers have found that people with schizophrenia are far more likely than other people to have a certain type of error in their genes. Scientists believe the finding will help them develop new treatments for schizophrenia and identify young people at high risk of developing the disorder.

To listen to the broadcast, click here.

Also see:







Disruption of Normal Gene Sequence May Lead to Schizophrenia





Study Ties Genetic Variations to Schizophrenia

The new analysis, to be published Friday in the journal Science, detected extremely rare and unknown mutations that turned up three to four times as often in people with schizophrenia as in those without it.

A New, Genetic Model for Schizophrenia






Schizophrenia Linked to Rare, Often Unique Genetic Glitches






Genetic Disturbance Linked to Schizophrenia