Project 1: Improving Accessibility and Personalization of Cognitive Remediation for Schizophrenia
Project leader: Dr. Alice Medalia
Click here for a link to the personnel in Project 1.
Contact: Shanique Y. Meyler
Consistent with the aims of the OPAL center, this project will explore adaptations of cognitive treatments for schizophrenia, with the goal of optimizing their effectiveness in real-world clinical settings and readiness for broad deployment. Schizophrenia is associated with cognitive deficits that negatively impact essential areas of daily functioning. NY State Office of Mental Health (OMH) is the first and largest state system of care to implement a statewide program of cognitive remediation (CR), an evidence-based practice for improving cognition and aiding functional recovery. Through Cognitive Remediation to Promote Recovery (CR2PR), CR is now offered in outpatient programs, with plans to expand to more services and further adapt implementation to improve treatment outcomes. This project will work directly with OMH clinics and clinicians, and draw on the resources of the Center’s trans-disciplinary expertise to build upon and improve current CR delivery methods.
This project will study the impact of two adaptations. One adaptation focuses on increasing the accessibility of the program, which participants report is limited by the requirement of twice weekly attendance. This project will therefore compare the feasibility and acceptability of delivering CR in either two clinic-based sessions (Clinic) or one clinic and one remote session (Hybrid) per week. Semi-structured qualitative interviews will be conducted with stakeholders to explore the impact of the adaptation. The second adaptation is intended to improve personalization of CR by systematically accounting for individual differences in neurocognitive needs. Drawing upon convergent evidence for tailoring CR based on need for early auditory processing (EAP) training, this project examines whether integrating a measure of EAP into the current baseline assessment facilitates personalization of the menu of restorative computer-based exercises used in CR. The team’s expertise in CR implementation and dissemination, clinical trials, and integrative quantitative and qualitative methods altogether support the aims of this project. Feasibility parameters and qualitative/quantitative data analyses of facilitators and barriers to Hybrid CR delivery will together inform further treatment refinement and the design of a larger effectiveness trial of Clinic versus Hybrid CR. We will study how EAP assessment is employed by practitioners to personalize the CR treatment plan and examine if EAP improvement is associated with cognitive outcomes in public practice CR settings. Finally, we will compare cognitive, functional, and service use outcomes in Hybrid versus Clinic CR and use exploratory methods to test whether subgroups of patients benefit more from Hybrid or Clinic delivery approaches. This project supports the mission of the Center, to rapidly translate laboratory evidence to clinical practice in a manner congruent with the realities of publicly funded clinics. By improving CR utilization and treatment outcomes in large systems of care, this project has the potential to impact the lives of many people with schizophrenia.
Project 2: Adapting Critical Time Intervention to Support Inpatient Medical Care Transitions
Project leader: Dr. Thomas Smith
Click here for a link to the personnel in Project 2.
Contact: Sarah Styke
For adults with schizophrenia, the transition from hospital inpatient to outpatient care poses substantial risks of treatment disengagement. Traditional case management approaches for patients with schizophrenia have involved telephonic follow-up after discharge from inpatient mental health care and have yielded poor results. Much less information exists regarding outcomes for patients with schizophrenia discharged following inpatient medical care. Given that these patients often have difficulty accessing and adhering to medical treatments, patients with schizophrenia who are admitted to a hospital for treatment of a medical condition are especially vulnerable to failed care transitions. Intensive interventions involving home visits, social support, motivational interviewing, and accompanying patients to outpatient appointments have shown positive results for patients discharged following inpatient mental health care, and may therefore be effective for patients with schizophrenia discharged following inpatient medical care.
Critical Time Intervention (CTI) is a novel evidence based time-limited intervention that involves ongoing community-based contacts with patients from trained care managers to facilitate connections to aftercare providers and community and support systems following hospital discharge. This pilot study will adapt CTI for use with patients with schizophrenia who are admitted to one of 2 safety net hospitals in Bronx, New York, for treatment of ambulatory care sensitive conditions (medical conditions for which appropriate ambulatory care should limit the need for inpatient treatment). We will randomize 80 eligible inpatients to receive either: 1) treatment as usual (TAU) (n=40); or 2) CTI and TAU (n=40). During a 3-month period prior to randomization, an Adaptation Team of research and hospital staff will review data from qualitative interviews of clinical staff and patients to identify factors likely to facilitate and impede CTI implementation. The team will then adapt the CTI to increase the likelihood of successful implementation. In the randomization phase, participants assigned to CTI will meet with a CTI care manger during their inpatient stay and over a 3-month period following hospital discharge. CTI care managers will assess and address patient needs and barriers to outpatient medical and mental health care and provide support and assistance with medical and mental health care management. For quantitative analyses, the primary outcome measures will be all-cause hospital readmissions at 7 and 30 days following discharge. Secondary outcomes will include follow-up with medical and mental health outpatient care at 7 and 30 days following hospital discharge. Patients receiving CTI will also be assessed to evaluate satisfaction with CTI services, psychiatric symptoms, community function, and involvement in medical care decisions. The proposed study will test whether a time-limited novel intervention helps overcome common barriers to adherence with outpatient medical and mental health care and reduces hospital readmissions for a vulnerable population.
Project 3: Using mHealth to optimize pharmacotherapy regimens
Project leaders: Drs. Scott Stroup and David Kimhy
Click here for a link to the personnel in Project 3.
Contact: Russell Tyler Rogers
Comprehensive early treatment of individuals experiencing schizophrenia has the potential to alter the course of illness and improve long-term outcomes. Psychotropic medications are a critical component of early treatment strategies. Because early experiences with medications may have an enduring effect on attitudes toward medications and adherence, first-episode psychosis (FEP) is a critical time to optimize prescribing. Yet evidence suggests that prescribing for this population is suboptimal, with many patients receiving higher than recommended dosages of antipsychotic medications and, for unclear indications, additional psychotropic medications. A contributing factor to these difficulties is the lack of accurate information about the effects of medications on symptoms, their side effects, as well as their behavioral, cognitive, and emotional correlates. At medication management appointments, prescribers typically rely on patients’ recollection of how they were doing over periods of weeks. Such retrospective assessments are problematic as they are vulnerable to the influence of memory difficulties and cognitive biases.
To address these issues, this project will use a smartphone technology to improve medication prescribing for individuals with FEP. We will collect real-time symptom and functioning data via smartphones to provide prescribers and other clinical team members with clinically relevant and time-sensitive information that will inform and promote shared decision making (SDM) and personalized interventions. The result will be a time-sensitive, data-driven, collaborative process to optimize medication regimens in order to maximize benefits, minimize harms, and promote adherence. We will conduct a pilot study in collaboration with OnTrackNY, an innovative coordinated specialty care (CSC) program for individuals aged 16-30 who are experiencing FEP. Participants will be randomized to receive the mHealth intervention or treatment as usual. We will evaluate the feasibility of the intervention and its effects on treatment satisfaction, functioning, quality of life, symptoms and side effects. This pilot study will provide feasibility data on an mHealth intervention that explicitly incorporates patient input, is scalable, and leads to improved, data-driven psychopharmacologic treatment.