Cognitive Adaption Training-Effectiveness in Real-world Settings and Mechanism of Action (CAT-EM)

Schizophrenia remains one of the most disabling conditions world-wide with an economic burden
that exceeded $155 billion dollars in fiscal year 2013 alone. Despite existing medication and
community treatment, many individuals with this diagnosis continue to have poor outcomes and
struggle toward recovery. CAT is a psychosocial treatment using environmental supports such
as signs, alarms, pill containers, checklists, technology and the organization of belongings
established in a person's home or work environment to bypass the cognitive and motivational
difficulties associated with schizophrenia, and support habits for functional behavior to
promote recovery. In a series of efficacy studies, CAT improved social and occupational
functioning, symptoms, and adherence to medication, and reduced rates of readmission. The
investigators propose a cluster randomized effectiveness trial comparing Cognitive Adaptation
Training (CAT) to existing community treatment (CT) for individuals with schizophrenia in 8
community mental health centers across multiple states including 400 participants. This would
be the first large-scale effectiveness study of CAT for improving functional outcomes for
those with schizophrenia seen in community mental health centers (CMHCs) where the majority
of those with schizophrenia are followed for outpatient care and to study the purported
mechanisms of action based on an integrated theoretical model. Participants will be assessed
at baseline and 6 and 12 months on measures of functional and community outcome, medication
adherence, symptoms, habit formation and automaticity, cognition and motivation. CAT
treatment will be weekly for 6 months, biweekly for 3 months and monthly for the remainder of
the trial. Purported mechanisms of action for CAT including bypassing impairments in
cognitive function to improve functional outcome and bypassing motivational impairments to
create automatic habits to improve functional outcome will be examined.

Inclusion Criteria:

1. Males and females who have given informed consent.

2. Between the ages of 18 and 65.

3. Clinical Diagnosis of Schizophrenia, or Schizoaffective Disorder

4. Able to provide evidence of a stable living environment (individual apartment, family
home, board and care facility) within the last three months and no plans to move in
the next year.

5. Able to understand and complete rating scales and assessments.

6. Agree to home visits

7. Be able to have reimbursed home visits as part of treatment

Exclusion Criteria:

1. Alcohol or drug or dependence within the past 2 months.

2. Currently being treated by an Assertive Community Treatment (ACT) team.

3. History of assault within the past year or other conditions that in the judgement of
the treatment team make home visits unsafe.