18.1 ENVIRONMENTAL SUPPORTS AND THE KITCHEN SINK: IMPROVING NEGATIVE SYMPTOMS IN SCHIZOPHRENIA

Abstract

Background: Among individuals with schizophrenia, those who have persistent and clinically significant negative symptoms (PNS) including restricted affect, diminished emotional range, poverty of speech, decreased motivation and interests, diminished sense of purpose and diminished social drive typically have the poorest functional outcomes and quality of life. The NIMH‐MATRICS Consensus Statement on Negative Symptoms indicated that these symptoms represent an unmet therapeutic need for large numbers of individuals with schizophrenia. In multiple studies across several decades, we found that Cognitive Adaptation Training (CAT; a series of environmental supports such as signs, checklists, alarms and the organization of belongings) improves motivation; one dimension of negative symptoms. Moreover, social and occupational functioning improves with CAT. In an effort to address the broad range of negative symptom domains, we developed the MOtiVation and Engagement (MOVE) program which is composed of 5 therapeutic approaches to improve negative symptoms and real‐world function. These include CAT to prompt task initiation and persistence, in‐vivo social skills training to ameliorate skills deficits and encourage appropriate interaction with individuals in the client's environment, cognitive behavioral techniques to address self‐defeating thoughts that mediate the relationship between negative symptoms and functional outcomes, in‐vivo training in emotional processing to address affective blunting and problems in identifying emotions, and specific techniques to address the deficits in anticipatory pleasure experienced by individuals with PNS. We review the data and results of these programs with a look to the future of treatments for negative symptoms. Methods: Three randomized trials 3 of Cognitive Adaptation Training and 1 of MOVE included 208 patients. In addition, an effectiveness trial included 241 patients. Patients were assessed at baseline and either every 3 months or monthly on measures of negative symptoms and functional outcomes. Data were analyzed using repeated measures analysis of variance for mixed models. Results: The one effectiveness trial of CAT found significant improvement over time only in the CAT group compared to standard community treatment on the Brief Negative Symptom Assessment. Randomized trials indicated improvement in the motivation factor on the Negative Symptom Assessment (NSA) for the CAT/MOVE groups compared to both active and standard treatment controls. Trials of MOVE also indicated improvement in the socialization and recreation on the Clinical Assessment Instrument for Negative Symptoms (CAINS). However, domains of emotion, psychomotor speed, and emotion and were not altered by either CAT or MOVE treatment. This is particularly disappointing give the focus of MOVE on a broad range of symptoms. In MOVE, negative symptoms improvements took 9 months of weekly treatment and required highly skilled therapists. Conclusions: Further investigation of a comprehensive treatments for PNS is warranted. New strategies for targeting multiple domains of negative symptoms are needed. Greater use of peer specialists may increase the reach of psychosocial treatments for negative symptoms and make them more economical. In the currently economically focused health care market, it is unclear that comprehensive treatments such as MOVE will be adopted unless reductions in caregiver burden or improvements in work outcomes could be demonstrated. Psychosocial treatments in combination with novel pharmaceutical agents should be considered.