Enhancing Assertive Community Treatment with CBT and SST for Schizophrenia

说明(由申请者提供)：精神分裂症患者以康复为导向的心理健康服务的质量已成为一个重要的研究重点，这反映在国家精神卫生中心战略目标3(改善治疗，使精神病患者过上充实和富有成效的生活)和目标4(更好地了解传播和实施干预措施的手段)。拟议的项目解决了这两个目标。积极的社区治疗(ACT)是在美国社区精神卫生(MH)项目中广泛实施的为数不多的针对精神分裂症的循证实践(EBP)之一，但ACT对功能几乎没有影响。认知行为疗法(CBT)和社交技能训练(SST)改善了患有精神分裂症的消费者的功能，但这些EBP在美国很少在ACT团队或其他社区MH计划中提供。该领域必须通过将针对精神分裂症的EBPS调整为在社区环境中提供来弥合研究和服务提供之间的差距。由于ACT被广泛实施，ACT团队为更广泛地实施CBT和SST等以恢复为导向的EBPS提供了独特的机会。此外，最需要干预以改善功能的低功能消费者通常被分配到ACT团队。我们开发了一种名为认知-行为社交技能训练(CBSST)的创新心理社会干预措施，它结合了CBT和SST来针对精神分裂症的功能。我们已经将CBSST用于ACT团队的实施，并在试点工作中证明了CBSST在圣地亚哥县精神卫生系统中由社区ACT工作人员提供时的可行性和足够的保真度。拟议的项目是一项有效性试验，比较了两种治疗精神分裂症的方法：单独使用ACT和CBSST。我们建议将176名精神分裂症或分裂情感障碍患者随机分配到两种治疗方法中的一种，为期9个月，并在治疗后进行纵向跟踪9个月。主要目的是检验ACT CBSST相对于ACT单独在心理社会功能方面的递增效果。通过增加CBSST来增强ACT被认为是为了改善ACT对功能结局的影响。我们还将研究CBSST中潜在的功能变化机制，包括提高社交能力和减少失败主义表现信念(例如，为什么要费力尝试，我总是失败)，这可能会干扰社区功能行为的表现。最后，将使用定性和定量相结合的方法来确定成功实施CBSST的障碍和促进者。这项研究将确定，当现实世界社区的ACT治疗师在复杂的社区实践环境中与现实世界的消费者一起提供时，通过增加CBT和SST干预来增强ACT是否可以改善精神分裂症患者的功能。如果ACT CBSST被发现增加了精神分裂症患者对社区的生产性贡献，这可能会对个人、社会和经济产生重大影响。

DESCRIPTION (provided by applicant): The quality of recovery-oriented mental health services for people with schizophrenia has become an important research focus, as reflected in NIMH Strategic Objectives 3 (improve treatments to allow those with mental illness live full and productive lives) and 4 (improve understanding of means by which interventions are disseminated and implemented). The proposed project addresses both of these objectives. Assertive community treatment (ACT) is one of the few evidence-based practices (EBPs) for schizophrenia that is widely implemented in community mental health (MH) programs throughout the USA, but ACT has little impact on functioning. Cognitive behavioral therapy (CBT) and social skills training (SST) improve functioning in consumers with schizophrenia, but these EBPs are rarely available in the USA in ACT teams or other community MH programs. The field must close the gap between research and service delivery by adapting EBPs for schizophrenia for delivery in community settings. Because ACT is widely implemented, the ACT team provides a unique opportunity for broader implementation of recovery-oriented EBPs like CBT and SST. In addition, lower functioning consumers who are most in need of interventions to improve functioning are typically assigned to ACT teams. We developed an innovative psychosocial intervention called cognitive- behavioral social skills training (CBSST), which combines CBT and SST to target functioning in schizophrenia. We have adapted CBSST for implementation on ACT teams and in pilot work have demonstrated feasibility and adequate fidelity of CBSST when delivered by community ACT staff in the San Diego County Mental Health System. The proposed project is an effectiveness trial comparing two treatments for schizophrenia: ACT+CBSST and ACT, alone. We propose to randomly assign 176 participants with schizophrenia or schizoaffective disorder to one of the two treatments for 9 months, and follow them longitudinally for 9 months after treatment. The primary aim is to examine the incremental effectiveness of ACT+CBSST relative to ACT, alone, on psychosocial functioning. Enhancing ACT by adding CBSST is hypothesized to improve the impact of ACT on functional outcome. We will also examine potential mechanisms of change in functioning in CBSST, including improving social competence and reducing defeatist performance beliefs (e.g., "Why bother trying, I always fail") that can interfere with performance of community functioning behaviors. Finally, mixed qualitative- quantitative methods will be used to identify barriers and facilitators of successful CBSST implementation. The study will determine whether enhancing ACT by adding CBT and SST interventions improves functioning in people with schizophrenia when delivered by real world community ACT therapists in complex community practice settings with real world consumers. If ACT+CBSST is found to increase productive community contributions in people with schizophrenia, this could have significant personal, societal, and economic impact.