Cognitive Behavior Therapy and Work Outcome

Objectives: The proposed grant seeks to compare the effects of a manualized form of
Cognitive Behavior Therapy (CBT) combined with Cognitive Remediation (CR) with CBT alone and
Support Services (SS) alone on vocational outcomes for persons with schizophrenia spectrum
disorders. Key hypotheses are: I) Participants receiving CBT +CR will work more weeks and
hours than participants receiving CBT alone or SS alone; II) Participants receiving CBT + CR
condition will show better work performance than the CBT alone and SS alone conditions; III)
Participants receiving CBT + CR will experience greater improvements in symptoms,
dysfunctional beliefs and quality of life than the CBT alone or SS alone conditions Research
Plan: One hundred twenty participants with Structured Clinical Interview for DSM-IV (SCID)
confirmed diagnoses of schizophrenia or schizoaffective disorder will be recruited from the
Roudebush VA Medical Center , surrounding mental health centers and the Marion VA Medical
Center. Participants with these diagnoses will be eligible if they are sufficiently stable
to sustain participant in rehabilitation, as defined by no hospitalizations, medication or
housing changes in the last 30 days. Participants will be offered a 6 month paid job
placement and randomly assigned to receive either CBT + CR, CBT only or SS only.

Methodology: Following informed consent, a baseline assessment will include an inventory of
work, residential, substance abuse, legal, quality of life, psychiatric and service
utilization history. Participants will be offered a 26-week job placement at the VA Medical
center or within the community and randomly assigned to receive 6 months of either CBT +CR,
CBT only or SS. Jobs will include entry-level positions supervised by regular job site
supervisors. Participants will be paid $3.50 per hour for up to 20 hours per week.
Participants in the SS condition will attend a weekly individual and support group offering
unstructured support regarding work related problems they identify. Participants in the CBT
group will attend weekly group and individual sessions employing a manualized CBT
intervention to identify and correct dysfunctional cognitions related to work. Participants
in the CBT + CR condition will attend meetings as indicated for CBT along with performing
cognitive exercises on the computer, progressing at their own pace. Hours of work will be
recorded weekly. Work performance will be measured biweekly. Symptoms and cognitions will be
assessed every 2 months. Primary forms of data analyses will be multivariate repeated
measure analyses of variance in which CBT +CR, CBT only and SS groups will be compared on
vocational, symptom, and self-esteem variables.

Results: The investigators have recently demonstrated in separate randomized controlled
trials that CBT and CR can be fully implemented in a VA setting and that each leads to
better work outcomes in schizophrenia. Means and standard deviations of key outcomes have
been determined and are used in the power analysis for this study.

Significance: The proposed research aims provide a scientifically sound exploration of the
therapeutic value of productive activity in the rehabilitation of persons with schizophrenia
and to determine the extent to which manualized CBT procedures when combined with CR may
contribute to the success of this process. Results may provide exportable guidelines for
augmenting work services with an appropriate psychological treatment. This information may
lead to more effective rehabilitation programs as well as increases in productivity,
functional independence and an enhanced quality of life for persons with schizophrenia. The
study also fulfills the rehabilitation goal of maximum inclusion by providing CBT and CR
services that may make it possible for some patients to function at work that otherwise
could not.

Inclusion Criteria:

- Diagnosis of schizophrenia spectrum disorder,

- interest in vocational rehabilitation

Exclusion Criteria:

- No changes in medication type or housing in the last 30 days,

- mental retardation