Treatment-resistant Psychosis Research Articles

Clozapine in a patient with treatment-resistant schizophrenia and hypertrophic cardiomyopathy: a case report.

BackgroundThere is currently limited experience in the initiation and maintenance of clozapine for treatment-resistant psychosis in adults with established structural heart disease. These complex patients require close supervision and liaison between colleagues. Here we present the successful experience of treating one such patient within our service and describe a monitoring plan to ensure that these treatments can be provided both safely and effectively.Case presentationA 36-year-old man with treatment-resistant schizophrenia and known hypertrophic cardiomyopathy (HCM) was admitted to a specialist unit for a trial of clozapine. His psychiatric illness was characterised by multimodal hallucinations and delusions combined with low mood and poor motivation. The diagnosis of HCM was made 3 years previously following a routine electrocardiogram (ECG), and he had remained asymptomatic throughout this time; there were concerns about the risk of initiating clozapine given his pre-existing cardiac condition.Baseline investigations were performed as per local guidelines prior to commencing clozapine; these were within normal limits other than a mildly raised troponin level of 54 ng/L (normal <16 ng/L), which was attributed to the HCM. In addition, baseline transthoracic echocardiography (TTE) was performed which showed no change in the structural heart disease in comparison with previous TTEs.Clozapine was started at 12.5 mg daily and up-titrated to 150 mg twice daily over 14 days as per our institute’s guidelines. The patient was monitored with regular testing of troponins, inflammatory markers and ECG. On day 18, the troponin level increased to 1371 ng/L. Creatine kinase and inflammatory markers remained stable. No changes in ECG or TTE were noted and the patient remained clinically asymptomatic.Cardiology opinion was sought and reported that the finding of an isolated elevated troponin was likely to reflect a ‘troponin leak’ in the context of increased cardiac muscle mass associated with HCM. In the absence of any clinical compromise, it was not felt to be of concern. Clozapine was continued with good effect on mental state. Troponin levels gradually reduced and the patient remained well.ConclusionsWhile multiple cases of clozapine-induced cardiotoxicity have been reported in the literature, its implications for pre-existing structural disease are unclear. This case report suggests that clozapine can be safely introduced in pre-existing HCM, explores strategies for monitoring and highlights the importance of liaising with experienced cardiologists.Declaration of interestNone.Copyright and usage© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Myocarditis in a patient on Clozapine: What did it?

We are presenting a case of 37-year-old male with schizoaffective disorder who developed myocarditis within 3 weeks of starting on clozapine for his treatment resistant psychosis. The patient also had a positive titer for Influenza A which makes it a diagnostic dilemma regarding the cause of his myocarditis. It may be possible that the myocarditis was caused by the Influenza A virus or synergistically exacerbated the clozapine's propensity to cause it. Currently, there are no studies establishing the link between the two etiologies. As clozapine can be the only option for patients resistant to treatment of their psychiatric illness and there being some evidence for successful re-challenge of clozapine, we consider that this patient could have benefitted from a trial of a re-challenge, however, was lost to follow up.

Clozapine for psychotic disorders in adults with intellectual disabilities.

Psychosis is three times more common in people with an intellectual disability than in those without an intellectual disability. A low intelligence quotient (IQ) is a defining characteristic for intellectual disability and a risk factor for poor outcome in psychosis. Clozapine is recommended for treatment-resistant psychosis. The effect of psychotropic medication can be different in people with intellectual disability; for example, they may be more prone to side effects. People with an intellectual disability and psychosis form a special subgroup and we wanted to examine if there is randomised controlled trial (RCT) data in this population to support the use of clozapine. To determine the effects of clozapine for treating adults with a dual diagnosis of intellectual disability and psychosis. We searched CENTRAL, Ovid MEDLINE, Embase and eight other databases up to December 2014. We also searched two trials registers, the Cochrane Schizophrenia Group's Register of Trials, and contacted the manufacturers of clozapine. RCTs that assessed the effects of clozapine, at any dose, for treating adults (aged 18 years and over) with a dual diagnosis of intellectual disability and psychotic disorder, compared with placebo or another antipsychotic medication. Three review authors independently screened all titles, abstracts and any relevant full-text reports against the inclusion criteria. Of the 1224 titles and abstracts screened, we shortlisted 38 full-text articles, which we subsequently excluded as they did not meet the inclusion criteria. These studies were not RCTs. Consequently, no studies are included in this Cochrane review. There are currently no RCTs that assess the efficacy and side effects of clozapine in people with intellectual disabilities and psychoses. Given the use of clozapine in this vulnerable population, there is an urgent need for a RCT of clozapine in people with a dual diagnosis of intellectual disability and psychosis to fill the evidence gap.

Treatment of refractory substance-induced psychosis in adolescent males with a genetic predisposition to mental illness

This article presents two cases of adolescent males who were admitted to our inpatient psychiatric unit with a psychotic, disorganized presentation. Both males had a genetic vulnerability to mental illness and reported significant substance use. Their symptoms were refractory to treatment and required the use of clozapine. Both patients experienced significant side effects, which limited the maximum daily dose of clozapine. However, they responded to a dose that was much lower than that typically used in adults. There is significant evidence in the literature about cannabis use triggering psychotic breaks in vulnerable individuals. We speculate that substance use (including synthetic cannabinoids) triggers treatment-resistant psychosis that requires the use of clozapine. Further, lower doses of clozapine may be sufficient to treat the substance-induced psychotic symptoms than those typically used in adult schizophrenia.

Clozapine-Induced Myocarditis: Is Mandatory Monitoring Warranted for Its Early Recognition?

Clozapine is an atypical antipsychotic used for treatment resistant schizophrenia. Its potential to induce agranulocytosis is well known but it can also cause myocarditis. Clozapine is the only antipsychotic known to induce this side effect, typically early in the treatment, and literature is scarce on this condition. We are presenting a case report of a 21-year-old schizophrenic male who developed myocarditis within 3 weeks of starting on clozapine for his treatment resistant psychosis. We then aim to review some of the available literature and raise awareness among physicians as this condition can potentially be fatal if not detected early.

What is “Effective Treatment” for a Schizophrenic Inpatient With Persistent Treatment-Resistant Psychosis and Severe Violent Behavior?

Aggressive behavior among treatment-resistant schizophrenic patients is a major clinical challenge whose prevalence is underestimated.In our 420-bed psychiatric hospital, some 15% of patients exhibit active psychosis and high rates of verbal/physical aggression necessitating physical restraints. In addition to their condition, these individuals endanger staff and other patients, consume extensive resources, and induce a sense of clinical helplessness.Physicians managing such complex patients face dilemmas regarding choice of treatment, criteria for treatment decisions, treatment goals, and outcome assessments. We address some of these by following the progress of a persistently psychotic severely aggressive treatment-resistant inpatient treated with repeated electroconvulsive therapy (ECT). The motivation for this report was our desire to examine whether there was objective evidence to support our clinically based treatment decisions.To this end, we compiled a retrospective chronological life chart recording ECT administrations and aggression using case note information. Physical restraint was chosen as the outcome measure, as it was accurately documented. Because it was used only after all other means failed, a recorded incident represents an extreme peak of ongoing aggressive behavior.

De novo treatment-resistant psychosis following thioridazine withdrawal

De novo treatment-resistant psychosis following thioridazine withdrawal

The Treatment of Hallucinations in Schizophrenia Spectrum Disorders

This article reviews the treatment of hallucinations in schizophrenia. The first treatment option for hallucinations in schizophrenia is antipsychotic medication, which can induce a rapid decrease in severity. Only 8% of first-episode patients still experience mild to moderate hallucinations after continuing medication for 1 year. Olanzapine, amisulpride, ziprasidone, and quetiapine are equally effective against hallucinations, but haloperidol may be slightly inferior. If the drug of first choice provides inadequate improvement, it is probably best to switch medication after 2-4 weeks of treatment. Clozapine is the drug of choice for patients who are resistant to 2 antipsychotic agents. Blood levels should be above 350-450 μg/ml for maximal effect. For relapse prevention, medication should be continued in the same dose. Depot medication should be considered for all patients because nonadherence is high. Cognitive-behavioral therapy (CBT) can be applied as an augmentation to antipsychotic medication. The success of CBT depends on the reduction of catastrophic appraisals, thereby reducing the concurrent anxiety and distress. CBT aims at reducing the emotional distress associated with auditory hallucinations and develops new coping strategies. Transcranial magnetic stimulation (TMS) is capable of reducing the frequency and severity of auditory hallucinations. Several meta-analyses found significantly better symptom reduction for low-frequency repetitive TMS as compared with placebo. Consequently, TMS currently has the status of a potentially useful treatment method for auditory hallucinations, but only in combination with state of the art antipsychotic treatment. Electroconvulsive therapy (ECT) is considered a last resort for treatment-resistant psychosis. Although several studies showed clinical improvement, a specific reduction in hallucination severity has never been demonstrated.

FC19-03 - Advances in cognitive behaviour therapy for psychosis

IntroductionCBT for psychosis has been developed over the past two decades and is now recommended by most clinical guidelines for schizophrenia internationally.Aims &amp; objectivesTo provide an up-date on advances and controversies in CBT for psychosis.MethodEvidence from recent meta-analyses (including Lynch et al, 2010) and randomised controlled trials will be reviewed. These have generally demonstrated effectiveness in early and treatment-resistant schizophrenia of CBT, and other specific indications, e.g. co-morbid substance misuse, aggressive behaviour, command hallucinations. Treatment is based on engaging the patient in a therapeutic relationship, developing an agreed formulation and then the use of a range of techniques for hallucinations, delusions and negative symptoms.ResultsEvidence of effectiveness in treatment-resistant psychosis remains strong but some areas for intervention remain under-researched. A series of studies are on-going which will provide more information about effective ways of working.ConclusionsCBT is a very important but under-used intervention which can make clinically significant differences to patient's lives.

Mindfulness Groups for Psychosis; Key Issues for Implementation on an Inpatient Unit

There is emerging evidence that mindfulness groups for people with distressing psychosis are safe and therapeutic. The present study aimed to investigate the feasibility of running and evaluating a mindfulness group on an inpatient ward for individuals with chronic and treatment resistant psychosis. Eight participants attended a 6-week mindfulness group on a specialist tertiary inpatient ward. This study demonstrated that mindfulness exercises were acceptable and well-tolerated by participants. Measuring outcome, systemic challenges and participant experience are discussed.

Clozapine for Treatment-Resistant Schizophrenia: National Institute of Clinical Excellence (NICE) Guidance in the Real World

Clozapine, a poorly tolerated antipsychotic drug, is widely recognized as the only efficacious option in treatment-resistant psychosis. The United Kingdom (U.K.) National Institute of Clinical Excellence (NICE) guidance for its consideration defined a threshold for treatment resistance substantially more liberal than that utilized in seminal studies of efficacy. This study documented adherence to NICE guidance in a patient group likely to be enriched for treatment resistance: 150 consecutive assertive outreach and former rehabilitation inpatients. Evidence of a NICE-compliant treatment trial was adduced from case notes: treatment resistance was determined through discussion with key workers about ongoing clinical problems, including treatment-resistant patients already on clozapine. Reasons for treatment-resistant patients not receiving clozapine were documented. Levels of ongoing clinical problems were compared between treatment-resistant patients on clozapine, treatment-resistant patients not on clozapine, and non-treatment-resistant patients. Patients' mean age was 41, with illness duration of 16 years. Twelve percent (18 patients) had not had a NICE-compliant trial of treatment, but all 3 treatment-resistant patients in this subgroup were on clozapine already. Forty-five percent of the whole group was treatment resistant: 54% of the treatment-resistant group was treated with clozapine. Of the remaining 46% (i.e., 31 treatment-resistant patients not taking clozapine), 16 refused and 15 could not be treated for medical reasons including the failure of previous trials and neutropenia. Levels of ongoing clinical problems were generally similar between clozapine-treated patients and nontreatment-resistant patients, with significantly greater problems in treatment-resistant patients not taking clozapine. However, positive symptoms remained relatively high in the clozapine group, while substance abuse was actually lower than in the other two groups, and there were no differences between any of the groups in depression and suicide risk. Tertiary referral assertive outreach and rehabilitation services include a higher proportion of treatment-resistant patients than secondary services, as appropriate. Most patients receive a NICE-compliant trial for the determination of pharmacological treatment resistance, but only just over half of the patients who need clozapine on clinical grounds are taking it. While half of these refuse, the rest encounter insuperable obstacles to treatment. In general, clozapine reduces levels of ongoing clinical problems to those of nontreatment-resistant patients. In view of the difficulties of delivering clozapine to treatment-resistant patients, the development of treatment resistance should be avoided if possible.

Clozapine-Resistant Psychosis, Smoking, and Caffeine: Managing the Neglected Effects of Substances That Our Patients Consume Every Day

More than 30% of patients with psychotic disorders who are refractory to antipsychotic treatment also fail to respond to clozapine. Despite the high prevalence of smoking and caffeine use in the psychiatric population, these habits are usually overlooked as factors contributing to antipsychotic treatment failure. We describe 2 male patients with severe treatment-resistant psychosis, one with schizophrenia and the other with bipolar affective disorder-both of whom smoked heavily, and the latter also consumed enormous amounts of caffeine-whose symptoms were refractory to clozapine. Both patients experienced a major, sustained amelioration of their psychotic symptoms when clozapine treatment was recommenced under supervision in the inpatient setting and the pharmacological interactions between clozapine, smoking, and caffeine were considered. Therapeutic strategies included gradual increases in daily doses of clozapine, monitoring clozapine plasma levels, using single daily doses of clozapine at night, and augmenting clozapine treatment with low doses of amisulpride, a selective antagonist at the dopamine D2 and D3 receptors. Smoking and excessive caffeine use are associated with poor therapeutic responses to clozapine and should be considered in the pharmacological management of treatment-refractory psychosis, regardless of the primary diagnosis.

High-Dose Olanzapine Orally Disintegrating Tablets for Treatment-Resistant Psychosis

Sir: Olanzapine is a thienobenzodiazepine antipsychotic that has a broad in vitro affinity for several receptors, including serotonergic, cholinergic, dopaminergic, and adrenergic receptors.1 Olanzapine is approved for treatment of psychoses at doses up to 20 mg/day.2 New research suggests benefits of higher doses of olanzapine.3 Anecdotal case reports highlight the benefits of olanzapine at 50 mg/day in patients with refractory schizoaffective disorders.4 In the United Kingdom, a trial of high-dose olanzapine (range, 20–60 mg/day) showed moderate to marked clinical improvement in patients with clozapine-resistant schizophrenia.5 Treatment-resistant psychosis is generally treated with clozapine, which requires frequent blood tests and is associated with several side effects, including weight gain, sedation, and agranulocytosis. Regular blood draws and the myriad of side effects often contribute to poor compliance with clozapine. However, when patients fail clozapine, few other options exist. We describe a patient who, after failing clozapine treatment, responded to the orally disintegrating formulation of high-dose olanzapine. Case report. Mr. A, a 44-year-old man, had a long history of schizoaffective disorder, bipolar type (DSM-IV criteria). Symptoms started at the age of 21 years and included auditory hallucinations, delusions of grandeur, and hyper-religiosity. He was hospitalized multiple times and, at the time of the presentation described here (1999), was being treated in an assertive community training (ACT) program. After several medication failures, including trials of risperidone, quetiapine, ziprasidone, and olanzapine, he started clozapine treatment. All previous antipsychotic medications were administered for an adequate duration at an adequate dose; the maximum dose of olanzapine prescribed in the past was 20 mg/day. He developed disabling fatigue soon after initiation of treatment with clozapine. He often missed his appointments because of his dislike of frequent blood tests; however, after staff members from ACT began working closely with Mr. A, his compliance improved, as demonstrated by therapeutic serum clozapine levels, but his psychosis continued. He subsequently stopped clozapine and had a relapse of symptoms, including an increase in hallucinations and delusions that required hospitalization. During hospitalization, Mr. A was administered the orally disintegrating formulation of olanzapine; this formulation improved his medication adherence, but his psychotic symptoms continued. After 2 weeks of treatment with olan-zapine, the dose was increased to 40 mg daily. He reported a decrease in auditory hallucinations and hyper-religiosity and continued to deny side effects. His family reported improvement in his social functioning and cognition. On the basis of his symptoms, olanzapine was titrated further to 60 mg daily. His condition improved, and he experienced no side effects. Over the next 3 months, his psychosis continued to decrease. His Brief Psychiatric Rating Scale6 score decreased from l4 (with clozapine) to 3 (with orally disintegrating olanzapine) on objective evaluation and from 6 to 2 on subjective evaluation. Disorganized thoughts and somatic preoccupations decreased significantly. His serum olanzapine level was 108.3 ng/mL (therapeutic range: 20–60 ng/mL). Mr. A had gained weight from 210 lb to 276 lb while taking a combination of valproic acid and clozapine prior to initiation of olanzapine. Weight gain and glucose dysregulation are known side effects associated with use of olanzapine.7–9 Several measures, including periodic monitoring of weight, diet management, and encouragement for regular exercise, were provided as part of the ACT program to counter the above-mentioned side effects. Mr. A was compliant with the recommendations and lost 10 lb over a period of 2 years. Periodic glucose monitoring showed no glucose dysregulation. Over the next year, he required no hospitalization, his level of independent functioning improved, and he resumed his education at a community college. The patient's improvement was probably multifactorial, but higher doses of olanzapine and the orally disintegrating formulation might have played a part. Use of olanzapine was not accompanied by the fatigue associated with clozapine and improved medication adherence. Prescribing guidelines for olanzapine suggest a maximum dose of 20 mg/day. Higher-dose olanzapine treatment has not been well researched, but in our patient, it was efficacious and produced fewer side effects than clozapine. Further, obviating the need for blood draws and use of orally disintegrating pills improved medication adherence and reduced the need for monitoring. Most importantly, the patient's symptoms improved without additional side effects. Since he had previously not responded to low-dose olanzapine, clinical improvement after starting higher doses of olanzapine suggests causality. Although more clinical trials are needed to establish the benefits of high-dose olanzapine treatment, it may be an option for patients with treatment-resistant psychosis. High-dose olanzapine in the orally disintegrating formulation offers several advantages, including ease of administration, limited need for blood draws, and potential for improved mood stabilization.

Electroconvulsive Monotherapy in the Treatment of Acute Confusion Psychosis

This report focuses on the successful treatment of a most acute case of confusion psychosis according to the concept of Karl Leonhard. The 18-year-old patient was hospitalized three times before the current episode and his case has been characterized as pharmacologically treatment-resistant psychosis since he failed to respond to any psychopharmacological therapy including sufficient clozapine medication. In the patient's history, typical and atypical antipsychotic as well as mood-stabilizing and sedating pharmacological treatments have been conducted. However, only adverse effects could be observed. When receiving electroconvulsive monotherapy (ECT), the patient showed a marked reduction of symptoms while experiencing no adverse effects. The implications of this finding are discussed with regard to Leonhard's diagnostic system.

Psychological Interventions in Early Psychosis

The effectiveness of psychological treatments in schizophrenia has been explored in controlled trials over the last 15 years leading to the conclusion that they are an important adjunct to antipsychotic medication in the treatment of the disorder. Family interventions and cognitive-behavioral treatments have received the most attention. However, studies have mainly been carried out with individuals with chronic, treatment-resistant psychosis, where participants have already been stabilized on antipsychotic medication, and there has been little evaluation of approaches with people with a first episode of schizophrenia. This article will review the literature relating to cognitive-behavioral individual and family interventions in early psychosis. The little evidence that exists suggests that family interventions and individual cognitive-behavioral interventions are acceptable to first-episode patients and that patients can be retained in treatment. In addition, some studies suggest that psychological treatments convey advantages over standard treatments for psychosis in terms of reducing the transition from pre-psychotic states to full-blown psychosis, reducing residual psychotic symptomatology, and improving caregiver outcomes. Considerable work is needed to elucidate the specific needs of first-episode patients and to rigorously evaluate the effectiveness of psychological interventions. The challenges to be met in developing treatments in this area relate to addressing the developmental needs of this group, incorporating substance use routinely into interventions, and developing treatments that are specific to the phase of illness that the individuals are experiencing.

Clozapine treatment of psychosis associated with velo‐cardio‐facial syndrome: benefits and risks

Clozapine is licensed for the treatment of psychotic illnesses resistant to other antipsychotic medications. Velo-cardio-facial syndrome (VCFS) is associated with a vulnerability to psychotic illness that may be resistant to treatment with conventional typical and atypical antipsychotics. A 32-year-old man with intellectual disability (ID) and a long history of treatment-resistant psychosis was found to have VCFS. Treatment with typical antipsychotic drugs and with one atypical olanzapine produced no improvement. Treatment with clozapine produced an improvement in psychotic symptoms and associated behavioural abnormalities, but caused hypersalivation, constipation and a seizure disorder. The latter led to two fractures, one requiring surgery. The addition of sodium valproate stopped seizures. Clozapine may improve psychotic symptoms for people with ID associated with VCFS, but clinicians should be alert for potential adverse effects.

Augmentation With Amisulpride for Schizophrenic Patients Nonresponsive to Antipsychotic Monotherapy

Despite the effectiveness of antipsychotic medications in treatment of schizophrenia, about 30% of patients who receive an adequate treatment have significant persisting symptoms. The problem of treatment-resistant psychosis is an important and difficult one. The aim of this study was to retrospectively evaluate the efficacy and safety of amisulpride augmentation in treatment-resistant schizophrenic patients. To the best of our knowledge, this is the first report about resistant schizophrenic and schizoaffective patients treated with the combinations of risperidone and amisulpride and ziprasidone and amisulpride. Data were collected from patient records. A total of 15 resistant schizophrenic patients (7 men, 8 women, 54.0 +/- 16.9 years old) were included in the study. Before addition of amisulpride, the patients were treated with monotherapy by atypical neuroleptics (clozapine, olanzapine, risperidone, or ziprasidone). The mean amisulpride dose was 693.3 +/- 279.6 mg/d. The mental state of 12 (80%) patients treated with combination was improved. Three (20%) patients showed no change in their mental state. Only 2 patients treated with a combination of risperidone and amisulpride had mild side effects. The results are preliminary and require confirmation in a randomized controlled trial. The authors suggest that amisulpride may be a promising option as an augmentation strategy in treatment-resistant schizophrenic patients.

Economic Outcomes of Risperidone in Comparison to Typical Neuroleptic Agents for Treatment-Resistant Psychosis: A Community-Based Study

Objective: To compare the costs of treatment for psychosis with risperidone and typical neuroleptics in severely ill outpatients treated in a community mental health setting. Methods: This was an open, retrospective, controlled cohort comparison of actual costs of psychiatric treatment in a group of 17 patients treated with risperidone for psychotic disorders and 15 typical neuroleptic-treated controls matched for severity of illness. Assignment to the two groups was nonrandomized, and outcome data were gathered for the duration of the study for each subject, with dropouts included. Results: Risperidone use did not lead to increased treatment expenses compared with typical neuroleptic use in a mean of approximately nine months follow-up. The median overall cost per patient per year was $2,703 in the risperidone group, compared with $2,551 in the typical neuroleptic group (p = 0.64). Increased drug costs (mean expenses per patient per year: $1,631 for risperidone vs. $357 for typical neuroleptics; p = 0.005) were offset by reduced expenses due to decreased hospitalization rates (mean expenses per patient per year: $1,379 for risperidone vs. $3,920 for typical neuroleptics; p = 0.04). Use of other outpatient services did not significantly differ between the two groups. Conclusions: Use of risperidone led to lower hospitalization rates in this severely ill sample and did not lead to greater overall expense than typical neuroleptic use.

Placement challenges: implications for long-term care of dementia sufferers.

Caregivers and long-term care staff seek appropriate placements for dementia sufferers, but there is little empirical research to guide such decision-making. However, recent national trends in mental health care have emphasized the placement of persons with serious mental illness in privatized, community-based residences. This body of empirical research has indicated that persons with psychosis, substance use disorder, assaultive behavior, and medication noncompliance have shorter tenure in these residential settings. These findings are also important for other, more traditional health care settings, as the patients discharged from community residences may require assistance on occasion from such other settings. This study continues the inquiry into the characteristics of patients with serious mental illness, who have shorter tenure in community residences. Dangerous behaviors, treatment-resistant psychosis, medical illnesses, and social-interpersonal skill deficiencies were common causes for discharge in this study. Since there remains a paucity of published empirical studies on the issue for patients with Alzheimer's disease and other dementias, we present the implications of, and guidelines for, addressing these issues in dementia sufferers in long-term care settings.

Cognitive Behavior Therapy for Psychosis: From Understanding to Treatment

Abstract Recent randomized controlled trials carried out in the UK suggest that there is now strong evidence for the efficacy of cognitive behavioral therapy in the management of people with chronic treatment resistant psychosis. At the core of this approach is a focus on the subjective needs of people with psychosis (in particular the experience of voices, paranoia, delusions, and depression) and an attempt to understand or make sense of these problems from the individual's perspective. The cognitive behavioral offers both a new set of therapeutic skills, which may be utilized by psychiatric rehabilitation practitioners (see Kuipers and Turkington), and a new way of thinking about the needs of people with psychosis. The implications of the cognitive behavioral model of people with chronic psychosis can therefore inform an approach to psychiatric rehabilitation in which goals of rehabilitation genuinely reflect the concerns of the individual with mental illness. In this paper we outline the clinical impli...