Social Occupational Functioning Research Articles

New Psychosocial Interventions for Bipolar Disorder: A Review of Literature and Introduction of the Systematic Treatment Enhancement Program

What is the evidence that psychosocial treatment adds to the efficacy of pharmacotherapy in forestalling episodes of bipolar disorder (BPD)? This article gives the rationale for including psychosocial intervention in the outpatient maintenance of BPD. Attention is placed on 4 psychosocial modalities that have achieved empirical support in randomized trials: family-focused psychoeducational treatment (FFT), cognitive-behavioral therapy (CBT), interpersonal and social rhythm therapy (IPSRT), and group psychoeducation. FFT, CBT, and IPSRT are being contrasted with a psychosocial control condition in the context of the ongoing, multicenter Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). The objectives, design, and potential contributions of the STEP-BD study are explained. Future directions for the evaluation and dissemination of manual-based psychosocial interventions are discussed. Keywords: psychosocial treatment; expressed emotion; pharmacology; psychotherapy, family therapy Pharmacotherapy is the first-line treatment for bipolar symptoms during the acute, stabilization, and maintenance phases of the disorder. There is increasing evidence, however, that adjunctive psychosocial treatment offers more positive outcomes for bipolar disorder (BPD) than medication with routine clinical care alone (Bauer, 2002; Craighead & Miklowitz, 2000; Huxley, Parikh, & Baldessarini, 2000; Miklowitz & Craighead, 2001). The purpose of this article is to (1) explain the rationale for the use of psychosocial treatment as an adjunct to pharmacotherapy during stabilization and maintenance treatment; (2) review the empirical literature on adjunctive family, individual, and group therapy in relapse prevention and symptom management, and (3) explain the purposes, hypotheses, and design of the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) a large-scale, multicenter effectiveness trial comparing four different forms of psychosocial intervention for acutely depressed bipolar patients (Sachs et al., 2003). Limitations of Pharmacotherapy in the Outpatient Maintenance of BPD Despite the clear benefits offered by mood stabilizers and other adjunctive pharmacotherapy for BPD (Goodwin & Ghaemi, 1998; McElroy & Keck, 2000; Thase & Sachs, 2000), a wealth of evidence suggests that these treatments are not enough by themselves to end the cycling and disability associated with the disorder. Ongoing recurrences and subsyndromal exacerbations appear to be the norm even with medication use (Gelenberg et al., 1989; Gitlin, Swendsen, Heller, & Hammen, 1995; Suppes, Dennehy, & Gibbons, 2000). Tohen, Waternaux, and Tsuang (1990), for example, found that relapses occurred in 72% of a Veterans Administration sample of BPD patients followed over 4 years, with the majority (51%) occurring during the first year. Likewise, Gitlin et al. (1995) found that 37% of outpatients in a university-based affective disorders clinic relapsed over 1 year, 60% over 2 years, and 73% over 5 years. Furthermore, a disturbingly low proportion of patients remains stable and symptom-free even when they do not relapse. After a first hospitalization for a bipolar, manic or mixed episode, only 26% of patients achieve a full symptomatic recovery over 12 months, and only 24% achieve full recovery of social-occupational functioning (Keck et al., 1998). Problems with medication adherence complicate the outpatient management of BPD (Goodwin & Jamison, 1990). Patients complain bitterly about side effects of mood stabilizers such as weight gain, nausea, or cognitive dysfunction. Others report enjoying their manic periods and that medications take away feelings of exhilaration and creativity, yet do little to alleviate their ongoing depression. Accordingly, it is not surprising that poor medication adherence has been found in one-half to two-thirds of patients within the first year of treatment, with some data suggesting a modal length of compliance with mood stabilizers of 2 months (Johnson & McFarland, 1996; Keck et al. …

Baseline personality functioning correlates with 6 month outcome in schizophrenia

Objective. – The assessment of outcome in schizophrenic patients should consider both the response to treatment and the recovery of social skills. The aim was to evaluate the outcome and related psychostructural and clinical factors in schizophrenic patients after they underwent 6 months of residential multimodal treatment. Method. – Fifty-two schizophrenic patients enrolled in a multimodal treatment program were included in the study. Symptomatology and social functioning were assessed with the Brief Psychiatric Rating Scale (BPRS) and the Social and Occupational Functioning Assessment Scale (SOFAS). The Karolinska Psychodynamic Profile (KAPP) was used for the psychostructural evaluation. Results. – After 6 months there was a significant improvement in the global scores of BPRS, SOFAS, and some areas of KAPP. The personality (KAPP) and social-occupational functioning (SOFAS) at baseline (T0) correlated with the global score of BPRS at 6 months (T6); moreover, SOFAS at T6 correlated with BPRS and KAPP at T0 and with the illness duration. Conclusion. – The better the personality functioning in schizophrenic patients the better seems to be the response to treatment, with regard to symptoms as well as rehabilitation. Personality assessment might be useful for the individualisation of therapies, even within the context of a standardised program.

Demographic predictors of response to medication withdrawal

A critical research goal is to identify modifiable risk factors leading to functional disabilities in young psychiatric patients. The authors developed a multidimensional trans-diagnostic predictive model of functional outcome in patients with the recent-onset of a psychiatric illness.Baseline clinical, psychosis-risk status, cognitive, neurological-soft-signs measures, and dopamine-related-gene polymorphisms (DRD1-rs4532, COMT-rs165599, and DRD4-rs1800955) were collected in 138 young non-psychotic outpatients.116 individuals underwent follow-up (mean = 2.2 years, SD = 0.9) examination. A binary logistic model was used to predict low-functioning status at follow-up as defined by a score lower than 65 in the social occupational functioning assessment scale.A total of 54% of patients experiences low functioning at follow-up. Attention, Avolition, and Motor-Coordination subscale were significant predictors of low-functioning with an accuracy of 79.7%. A non-significant trend was found for a dopamine-related-gene polymorphism (DRD1-rs4532). The model was independent of psychotic-risk status, DSM-diagnosis, and psychotic conversion.A trans-diagnostic approach taking into account specific neurocognitive, clinical, and neurological information has the potential to identify those individuals with low-functioning independent of DSM diagnosis or the level of psychosis-risk.Specific early interventions targeting modifiable risk factors and emphasize functional recovery in young psychiatric samples, independent of DSM-diagnosis and psychosis-risk, are essential.