RESUMEN
OBJECTIVE: Functional impairments are debilitating concomitants of psychotic disorders and are present early in the illness course and, commonly, prior to psychosis onset. The factors affecting social and role functioning in early psychosis (EP) following treatment are unclear. We evaluated whether six months of participation in the PREP(R), Boston, EP treatment program, part of a public-academic community mental health center, was related to improvements in social and role functioning and whether premorbid adjustment in adolescence, baseline neurocognition, and depression symptoms predicted functional improvement. METHOD: The Global Functioning Social and Role scales, MATRICS neurocognitive battery, and Calgary Depression Scale were assessed at baseline and six months during naturalistic treatment, while premorbid adjustment was measured at baseline. All participants were psychotic disorder patients in PREP(R) (n = 46 with social functioning and 47 with role functioning measures at both time points). RESULTS: Large improvements were observed in role functioning (d = 0.84) and medium to large improvements were observed in social functioning (d = 0.70). Models consisting of adolescent premorbid adjustment and change in depression symptoms predicted social and role functioning change, whereas neuropsychological functioning did not. CONCLUSIONS: Substantial improvements in social and role functioning were observed among this sample participating in a recovery-based EP program. The impact of clinical factors on social and role functioning was highlighted. Further studies of premorbid adjustment in adolescence and the treatment of depression in EP programs in controlled treatment trials are needed to confirm these findings.
Asunto(s)
Cognición , Depresión/diagnóstico , Trastornos Psicóticos/diagnóstico , Rol , Esquizofrenia/diagnóstico , Conducta Social , Adolescente , Adulto , Diagnóstico Precoz , Femenino , Humanos , Masculino , Modelos Psicológicos , Pruebas Neuropsicológicas , Escalas de Valoración Psiquiátrica , Adulto JovenRESUMEN
Recently, there has been increasing emphasis on early intervention (EI) for psychotic disorders. EI programs in public mental health settings have been established in countries such as Australia, the United Kingdom, and Canada. However, there are relatively few EI programs in the United States (U.S.). Here we describe the conceptual origins and practical development of the PREP program, i.e., Prevention and Recovery in Early Psychosis, as it evolved in a public academic psychiatry setting in Boston, Massachusetts, U.S. PREP developed over a decade through a partnership between the Massachusetts Department of Mental Health and academic institutions within the Harvard Department of Psychiatry. We discuss the evolution, programmatic features, funding mechanisms, staffing, and the role of clinical training in PREP. The key principles in developing the PREP Program include the focus on early, evidence based, person-centered and phase-specific, integrated and continuous, comprehensive care. This program has served as a foundation for the emergence of related services at our institution, including a research clinic treating those at clinical high risk or within the putative "prodromal" period preceding frank psychosis. This account offers one possible blueprint for the development of EI programs despite the lack in the U.S. of a national mandate for EI or prevention-based mental health programs.
Asunto(s)
Intervención Médica Temprana/métodos , Desarrollo de Programa/métodos , Trastornos Psicóticos/terapia , Regionalización/métodos , Adolescente , Adulto , Boston , Conducta Cooperativa , Diagnóstico Precoz , Medicina Basada en la Evidencia , Femenino , Humanos , Masculino , Atención Dirigida al Paciente/métodos , Trastornos Psicóticos/diagnóstico , Adulto JovenRESUMEN
OBJECTIVE: To test the influence of neurocognitive functioning on community functioning among formerly homeless persons with serious mental illness and to determine whether that influence varies with social context, independent of individual characteristics. METHODS: In metropolitan Boston, 112 persons in Department of Mental Health shelters were administered a neuropsychological test battery and other measures and then randomly assigned to empowerment-oriented group homes or independent apartments, as part of a longitudinal study of the effects of housing on multiple outcomes. Subjects' case managers completed Rosen's 5-dimensional Life Skills Inventory at 3, 6, 12, and 18 months and subjects reported on their social contacts at baseline, 6, 12, and 18 months. Subject characteristics are controlled in the analysis. RESULTS: Three dimensions of neurocognitive functioning--executive function, verbal declarative memory, and vigilance--each predicted community functioning. Better executive function predicted improved self-care and less turbulent behavior among persons living alone, better memory predicted more positive social contacts for those living in a group home, and higher levels of vigilance predicted improved communication in both housing types. CONCLUSION: Neurocognition predicts community functioning among homeless persons with severe mental illness, but in a way that varies with the social context in which community functioning occurs.
Asunto(s)
Encéfalo/fisiopatología , Trastornos del Conocimiento/epidemiología , Trastornos del Conocimiento/fisiopatología , Personas con Mala Vivienda/psicología , Personas con Mala Vivienda/estadística & datos numéricos , Trastornos Mentales/epidemiología , Trastornos Mentales/terapia , Medio Social , Trastornos del Conocimiento/diagnóstico , Servicios Comunitarios de Salud Mental , Humanos , Trastornos Mentales/psicología , Estudios Prospectivos , Encuestas y Cuestionarios , Factores de TiempoRESUMEN
OBJECTIVE: To test the effect of living in group housing rather than independent apartments on executive functioning, verbal memory and sustained attention among formerly homeless persons with serious mental illness and to determine whether substance abuse modifies this effect. METHOD: In metropolitan Boston, 112 persons in Department of Mental Health shelters were randomly assigned to group homes ("Evolving Consumer Households", with project facilitator, group meetings, resident decision-making) or independent apartments. All were case managed. A neuropsychological test battery was administered at baseline, at 18 months (Time 2), with an 81% follow-up rate, and at 48 months (Time 3), with a 59% follow-up rate. Hierarchical Linear Modeling was applied to executive functioning--assessed with the Wisconsin Card Sorting Test (Perseverations)-Logical Memory story recall, and an auditory Continuous Performance Test (CPT) for sustained attention. Subject characteristics were controlled. RESULTS: When moved to group homes, subjects without a lifetime substance abuse history improved on Perseverations, while those who moved to independent apartments deteriorated on Perseverations. Across the two housing conditions, subjects showed no change in Perseverations, but improved on Logical Memory story recall and the CPT. CONCLUSIONS: Type of housing placement can influence cognitive functioning; notably, socially isolating housing is associated with weakened executive functioning. Substance abuse significantly diminishes environmental effects. These are important factors to consider in housing placement and subsequent treatment.
Asunto(s)
Cognición , Hogares para Grupos , Personas con Mala Vivienda/psicología , Esquizofrenia/rehabilitación , Psicología del Esquizofrénico , Trastornos Relacionados con Sustancias/psicología , Boston , Diagnóstico Dual (Psiquiatría) , Femenino , Humanos , Modelos Lineales , Masculino , Pruebas Neuropsicológicas , Características de la Residencia , Trastornos Relacionados con Sustancias/rehabilitaciónRESUMEN
The authors tested the hypotheses that neuropsychological functioning would improve after homeless persons with severe and persistent mental illness were provided with housing and that executive functioning would improve more among those placed in group homes than among those placed in independent apartments. A total of 114 persons with serious and persistent mental illness who were stable residents of homeless shelters completed neuropsychological testing and were randomly assigned to group homes or independent apartments; 91 participants (52 assigned to group homes and 39 assigned to independent apartments) were retested after 18 months. Overall neuropsychological functioning improved significantly across the full study sample. Executive performance, measured by the Wisconsin Card Sorting Test, decreased significantly among persons assigned to independent apartments and increased, but not significantly, among those assigned to group homes. The findings suggest that providing housing for persons who have severe and persistent mental illness improves cognitive functioning but that independent living may diminish executive functioning.