Treatments
Medication. All participants received Food and Drug Administration-approved antipsychotic medications for the treatment of schizophrenia, schizoaffective disorder, and schizophreniform disorder as indicated by a study psychiatrist. Medication changes were allowed, although every effort was made to stabilize participants on a tolerable and efficacious antipsychotic regimen before the initiation of psychosocial treatment. All participants were seen by a clinical nurse specialist at least biweekly to monitor medication side effects and efficacy. Most participants (>98%) were given second-generation antipsychotics throughout the study, and no significant differences emerged with regard to antipsychotic dosage, type, or clinician-estimated compliance between treatment groups. [A table detailing the between-group differences in baseline demographic, clinical, and medication characteristics is available as an online supplement to this article at ps.psychiatryonline.org.]
Cognitive enhancement therapy. CET is a comprehensive, developmental approach to the remediation of social and nonsocial cognitive deficits in schizophrenia. It seeks to facilitate the development of adult social-cognitive milestones (such as perspective taking and appraisal of one's social context) by shifting thinking from reliance on effortful, serial processing to a "gistful" and spontaneous abstraction of social themes. The treatment consists of approximately 60 hours of computer-assisted neurocognitive training in attention, memory, and problem solving and 45 social-cognitive group sessions that use experiential learning opportunities to foster the development of social wisdom and success in interpersonal interactions. A broad, theoretically driven array of social-cognitive abilities are targeted in the social-cognitive groups, which range from abstracting the "gist" or main point in social interactions to perspective taking, social context appraisal, and emotion management (39,43). Participants engage in the social-cognitive groups by responding to unrehearsed social exchanges, presenting homework, participating in cognitive exercises that focus on experiential learning, providing feedback to peers, and chairing homework sessions. CET typically begins with approximately three months of weekly one-hour neurocognitive training in attention, after which participants begin the weekly 1.5-hour social-cognitive groups. Neurocognitive training then proceeds concurrently with social-cognitive groups throughout the remaining course of treatment. A complete description of the treatment has been provided elsewhere (16).
Enriched supportive therapy. Enriched supportive therapy (EST) is an illness management and psychoeducation approach that draws on components of the basic and intermediate phases of the demonstrably effective personal therapy (44). In this approach, outpatients are seen on an individual basis to learn and practice stress management techniques designed to forestall late postdischarge relapse and enhance adjustment. The EST treatment is divided into two phases. Phase 1 focuses on basic psychoeducation about schizophrenia, the role of stress in the disorder, and ways to avoid or minimize stress. Phase 2 involves a personalized approach to the identification and management of life stressors that pose particular challenges to adequate social and role functioning. Participants move through the two phases of EST at their own pace, although each phase is typically provided for a year. By design, phase 1 was provided on a weekly basis, and phase 2 was provided on a biweekly basis. Although no attempt was made to match CET and EST approaches with regard to hours of treatment, EST served as the active control for this trial, in part to control for the potential effects on outcome of illness management and education interventions (45), which are provided in both CET and EST. All psychosocial interventions were administered by three master's-level psychiatric nurse specialists, and clinical supervision was provided by the two treatment developers.
Cognitive Enhancement Therapy for Early-Course Schizophrenia: Effects of a Two-Year Randomized Controlled Trial
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