XII. Psychological and Psychosocial Disorders

[226] REHABILITATION EFFECTS OF PAY, ACTIVITY, AND SUPPORT INTENSITY ON SCHIZOPHRENIA

Morris Bell, PhD; Gary Bryson, MA
VA Medical Center, West Haven, CT 06516

Sponsor: Department of Veterans Affairs, VA Rehabilitation Research and Development Service, Washington, DC 20420
(Project #D828-2RA)

PURPOSE--This research investigates the benefits of productive activity in the rehabilitation of patients with schizophrenia. Key questions are: 1) does pay increase participation in work activity and lead to higher rates of work placement in the community? 2) do higher intensity services yield better clinical outcomes than standard services? 3) is greater productivity associated with better clinical outcomes? and 4) is performance on psychological and neuropsychological measures a useful predictor of rehabilitation outcomes?

METHODOLOGY--One hundred and twenty patients with DSM III-R confirmed diagnoses of schizophrenia and schizoaffective disorder are being recruited from the general psychiatric service and stratified by prior work function. Subjects are randomly assigned to one of two levels of pay: $3.40 per/hour up to 20 hrs weekly or no remuneration; and one of two levels of support, standard or high. High support subjects have access to a job coach, attend a weekly group meeting where vocational issues are addressed, and are provided biweekly work performance feedback. All subjects are offered 6-month work placements. Research staff perform biweekly evaluations of job performance using the Work Behavior Inventory (WBI), symptom levels using the Positive and Negative Syndrome Scale (PANSS), and quality of life (QOL). Subjects are evaluated at baseline, 5 mo, 1 yr, and follow-up on demographic, neuro-behavioral and productivity variables.

PROGRESS--We have had over 115 referrals, of which 110 have completed all intake procedures and have been randomized into the study. This rate is slightly lower than planned, due almost exclusively to a change in the work group composition that necessitated a training period for the new members. However, we expect to recruit the planned 120 subjects about 2 mo behind schedule. Currently, 62 subjects have been assigned to the pay condition and 48 to the no pay condition; 55 to the standard support condition and 55 to the high support condition. Of the 110 subjects who have completed intake procedures, 83 have elected to continue to participate following randomization. As a group, these subjects have worked 15,649.75 hours, and we have performed 579 WBIs on them and conducted 122 weekly high support meetings. At 87 percent, attendance for group meetings has been excellent, and there has been surprisingly lively participation on the part of even the most withdrawn and symptomatic subjects. Also, we have conducted 642 weekly PANSS interviews, 329 QOL interviews, 520 group questionnaires, and 232 Job Satisfaction Inventories. In total we have conducted 1723 weekly assessments. Follow-up data are being gathered. 89 out of 95 subjects (94 percent) due for 5-mo follow-up have completed that procedure. Of those not completing it, two have died and four refused. Reevaluation of baseline measures for all subjects at 1 yr is concurrently being conducted. Of the 77 subjects in the program for 1 yr, 68 (89 percent) have completed the 1-yr follow-up battery.

RESULTS--With 85 percent of the total sample collected, we have not yet attempted to answer the primary questions outlined in the objectives section; however, a preliminary look at the data shows subjects in the high support condition work approximately 12 percent more than those in the standard condition, and all of the paid participants had at least 1 wk of work while only 50 percent of the unpaid participants worked at least 1 wk. Other analysis include a validation study verifying the psychometric properties of the WBI and the Wisconsin Card Sorting Test. We also have completed several investigations on cognitive impairment in schizophrenia, including: 1) the identification through a taxometric analysis of a cognitively disorganized subtype of schizophrenia; 2) the relationship of cognitive impairment to insight in schizophrenia; 3) patterns of cognitive impairment in deficit and nondeficit forms of schizophrenia; and 4 ) the cognitive predictors of improved work performance over time in schizophrenia. We have also investigated the influence of personality variable of work performance.

RECENT PUBLICATIONS FROM THIS RESEARCH

• Affect recognition deficits in schizophrenia: a function of global impairment or a specific cognitive deficit. Bryson G, Bell M, Lysaker P, Greig T, Kaplan E. Psychiatr Res. In press.
• Clinical benefits of paid work activity in schizophrenia: 1-year follow up. Bell MD, Lysaker PH. Schizophr Bull 1997;23(2):317-325.
• Cognitive dysfunction and impaired insight in schizophrenia. Lysaker P, Bell M, Bryson G, Kaplan E. Acta Scand. In press.
• Cognitive impairment and substance abuse history as predictors of the temporal stability of negative symptoms in schizophrenia. Lysaker PH, Bell MD, Bioty SM, Zito WS. J Nerv Ment Dis 1997;185:21-5.
• The work behavior inventory: a scale for the assessment of work behavior for clients with severe mental illness. Bryson G, Bell M, Lysaker P, Zito W. Psychiatr Res J 1997;20(4):47-55.
• WCST dimensions in schizophrenia: factorial, predictive and divergent validity. Bell M, Greg T, Kaplan E, Bryson G. J Exp Clin Neuropsych. In press.

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