Enhancing Assertive Community Treatment with CBT and SST for Schizophrenia

描述（由申请人提供）：精神分裂症患者康复导向的心理健康服务的质量已经成为一个重要的研究焦点，这反映在NIMH战略目标3（改善治疗方法，使精神疾病患者过上充实而富有成效的生活）和4（提高对干预措施传播和实施手段的理解）中。拟议的项目解决了这两个目标。自信的社区治疗（ACT）是精神分裂症的少数循证实践（ebp）之一，在整个美国的社区精神卫生（MH）项目中广泛实施，但ACT对功能的影响很小。认知行为疗法（CBT）和社会技能训练（SST）可以改善精神分裂症患者的功能，但这些ebp在美国的ACT团队或其他社区MH项目中很少可用。该领域必须缩小研究和服务提供之间的差距，使精神分裂症的EBPs适应社区环境。由于ACT被广泛实施，ACT团队为更广泛地实施面向恢复的ebp（如CBT和SST）提供了独特的机会。此外，最需要干预以改善功能的功能较低的消费者通常被分配到ACT小组。我们开发了一种创新的社会心理干预，称为认知行为社会技能训练（CBSST），它结合了CBT和SST来针对精神分裂症的功能。我们已经对CBSST进行了调整，以便在首都地区的团队中实施，在试点工作中，由圣地亚哥县精神卫生系统的首都地区社区工作人员提供CBSST的可行性和足够的保真度。拟议的项目是一项比较两种治疗精神分裂症的有效性试验：ACT+CBSST和ACT单独治疗。我们建议将176名精神分裂症或分裂情感性障碍患者随机分配到两种治疗方案中的一种治疗方案中，为期9个月，并在治疗后进行9个月的纵向随访。主要目的是检查ACT+CBSST相对于单独ACT对社会心理功能的增量有效性。假设通过添加CBSST来增强ACT可以改善ACT对功能结果的影响。我们还将研究CBSST中功能变化的潜在机制，包括提高社会能力和减少可能干扰社区功能行为表现的失败主义表现信念（例如，“为什么要努力，我总是失败”）。最后，将使用混合定性和定量方法来确定成功实施CBSST的障碍和促进因素。该研究将确定，当现实世界社区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ACT时，通过添加CBT和SST干预措施来增强ACT是否能改善精神分裂症患者的功能。如果发现ACT+CBSST可以增加精神分裂症患者的生产性社区贡献，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.