Enhancing assertive community treatment with cognitive behavioral social skills training for schizophrenia: study protocol for a randomized controlled trial.

BackgroundSchizophrenia leads to profound disability in everyday functioning (e.g., difficulty finding and maintaining employment, housing, and personal relationships). Medications can effectively reduce positive symptoms (e.g., hallucinations and delusions), but they do not meaningfully improve daily life functioning. Psychosocial evidence-based practices (EBPs) improve functioning, but these EBPs are not available to most people with schizophrenia. The field must close the research and service delivery gap by adapting EBPs for schizophrenia to facilitate widespread implementation in community settings. Our hybrid effectiveness and implementation study represents an initiative to bridge this divide. In this study we will test whether an existing EBP (i.e., Cognitive Behavioral Social Skills Training (CBSST)) modified to work in practice settings (i.e., Assertive Community Treatment (ACT) teams) commonly available to persons with schizophrenia results in better consumer outcomes. We will also identify key factors relevant to developing future CBSST implementation strategies.Methods/designFor the effectiveness study component, persons with schizophrenia will be recruited from existing publicly funded ACT teams operating in community settings. Participants will be randomized to one of the 2 treatments (ACT alone or ACT + Adapted CBSST) and followed longitudinally for 18 months with assessments every 18 weeks after baseline (5 in total). The primary outcome domain is psychosocial functioning (e.g., everyday living skills and activities related to employment, education, and housing) as measured by self-report, testing, and observation. Additional outcome domains of interest include mediators of change in functioning, symptoms, and quality of services. Primary analyses will be conducted using linear mixed-effects models for continuous data. The implementation study component consists of a structured, mixed qualitative-quantitative methodology (i.e., Concept Mapping) to characterize and assess the implementation experience from multiple stakeholder perspectives in order to inform future implementation initiatives.DiscussionAdapting CBSST to fit into the ACT service delivery context found throughout the United States creates an opportunity to substantially increase the number of persons with schizophrenia who could have access to and benefit from EBPs. As part of the implementation learning process training materials and treatment workbooks have been revised to promote easier use of CBSST in the context of brief community-based ACT visits.Trial registrationClinicalTrials.gov NCT02254733 . Date of registration: 25 April 2014

Circulation and hydrological characteristics of the North Aegean Sea: a contribution from real-time buoy measurements

In the framework of the POSEIDON Project, a network of open sea oceanographic buoys equipped with meteorological and oceanographic sensors has been operational in the Aegean Sea since 1998. The analysis of upper-ocean physical data (currents at 3m, temperature and salinity at 3-40m depths) collected during the last 2 years from the stations of the North Aegean basin indicates a strong temporal variability of flow field and hydrological characteristics in both synoptic and seasonal time scales. The northern part of the basin is mainly influenced by the Black Sea Water outflow and the mesoscale variability of the corresponding thermohaline fronts, while the southern stations are influenced by the general circulation of the Aegean Sea with strong modulations caused by the seasonally varying atmospheric forcing

Temperature and salinity variability in the Greek Seas based on POSEIDON stations time series: preliminary results

Temperature and salinity time series provided by three POSEIDON monitoring stations (buoys) are examined in order to study the seasonal and interannual variability of the water mass characteristics. The sites at Athos (North Aegean Sea), E1M3A (Central Cretan Sea) and Pylos (Eastern Ionian Sea) were chosen, as these buoys provide measurements at various depths, while they represent 3 major basins respectively. The study of the T and S characteristics reveals important seasonal changes and highlights the particular characteristics of each basin. Dense water production in the Northern Aegean is found to be hindered by the presence of the surface Black Sea Water (BSW) mass. On the other hand, the intermediate water mass in the Cretan Sea is shown to be ventilated during the winter season. A significant temperature and salinity increase has been monitored over both the Central Cretan and Eastern Ionian Seas starting from the middle of 2008 and 2009 respectively. This could possibly be attributed to changes in the intermediate water masses of the Eastern Mediterranean, without ruling out the possibility of water mass exchanges between the two basins

A 2-year intercomparison of the WAM-Cycle4 and the WAVEWATCH-III wave models implemented within the Mediterranean Sea

In this work we present the implementation of a wave forecast/hindcast system for the Mediterranean Sea at a 1/10º horizontal resolution and we show a first assessment of its performance by inter-comparing model results to observational data time series at selected points for the period 2000-2001. The system which is part of the POSEIDON-II operational system includes the WAM – Cycle4 and the WAVEWATCH-III wave forecast models (implemented within the same region) one way coupled with the non-hydrostatic version of the ETA atmospheric model which provides at 3-hour intervals the necessary wind velocity fields to the wave models. The same system but based on the WAM-Cycle4 wave model, has been used in the past for the production of the Aegean Sea wind and wave Atlas. Overall, the inter-comparison shows that both wave models are rather skilful in predicting the integral wave parameters with significant wave height skill scores in the range 0.85-0.90 and mean period scores in the range 0.77-0.83. It is also evident that WAM model has a tendency to overestimate mean wave periods while the opposite is true for WAVEWATCH-III model. Differences between the two models simulated spectra exist along the main passage of cyclonic systems over the Mediterranean Sea while in the wind seas dominated areas of the basin (the Aegean Sea for example) the two models show almost the same behavior

Dynamic downscaling of the ERA-40 data using a mesoscale meteorological model

A sophisticated downscaling procedure that was applied to reproduce high resolution historical records of the atmospheric conditions across the Mediterranean region is presented in this paper. This was accomplished by the dynamical downscaling of the European Center for Medium-Range Forecasts ERA-40 reanalyses with the aid of the atmospheric model of the POSEIDON weather forecasting system. The full three dimensional atmospheric fields with 6 hours of temporal resolution and the surface meteorological parameters at hourly intervals were produced for a 10-year period (1995-2004). The meteorological variables are readily available at 10 km resolution and may constitute the atmospheric forcing to drive wave, ocean hydrodynamic and hydrological models, as well as the baseline data for environmental impact assessment studies. A brief overview of the procedure and a quantitative estimation of the benefit of the new dynamical downscaling dataset are presented

Using a stakeholder-engaged, iterative, and systematic approach to adapting collaborative decision skills training for implementation in VA psychosocial rehabilitation and recovery centers

Background: Adaptation of interventions is inevitable during translation to new populations or settings. Systematic approach to adaptation can ensure that fidelity to core functions of the intervention are preserved while optimizing implementation feasibility and effectiveness for the local context. In this study, we used an iterative, mixed methods, and stakeholder-engaged process to systematically adapt Collaborative Decision Skills Training for Veterans with psychosis currently participating in VA Psychosocial Rehabilitation and Recovery Centers. Methods: A modified approach to Intervention Mapping (IM-Adapt) guided the adaptation process. An Adaptation Resource Team of five Veterans, two VA clinicians, and four researchers was formed. The Adaptation Resource Team engaged in an iterative process of identifying and completing adaptations including individual qualitative interviews, group meetings, and post-meeting surveys. Qualitative interviews were analyzed using rapid matrix analysis. We used the modified, RE-AIM enriched expanded Framework for Reporting Adaptations and Modifications to Evidence-based interventions (FRAME) to document adaptations. Additional constructs included adaptation size and scope; implementation of planned adaptation (yes–no); rationale for non-implementation; and tailoring of adaptation for a specific population (e.g., Veterans). Results: Rapid matrix analysis of individual qualitative interviews resulted in 510 qualitative codes. Veterans and clinicians reported that the intervention was a generally good ft for VA Psychosocial Rehabilitation and Recovery Centers and for Veterans. Following group meetings to reach adaptation consensus, 158 adaptations were completed. Most commonly, adaptations added or extended a component; were small in size and scope; intended to improve the effectiveness of the intervention, and based on experience as a patient or working with patients. Few adaptations were targeted towards a specific group, including Veterans. Veteran and clinician stakeholders reported that these adaptations were important and would benefit Veterans, and that they felt heard and understood during the adaptation process. Conclusions: A stakeholder-engaged, iterative, and mixed methods approach was successful for adapting Collaborative Decision Skills Training for immediate clinical application to Veterans in a psychosocial rehabilitation center. The ongoing interactions among multiple stakeholders resulted in high quality, tailored adaptations which are likely to be generalizable to other populations or settings. We recommend the use of this stakeholder-engaged, iterative approach to guide adaptations

A randomised controlled trial of cognitive behaviour therapy for psychosis in a routine clinical service

Objective: To evaluate CBTp delivered by non-expert therapists, using CBT relevant measures. Methods: Participants (N=74) were randomised into immediate therapy or waiting list control groups. The therapy group was offered six months of therapy and followed up three months later. The waiting list group received therapy after waiting nine months (becoming the delayed therapy group). Results: Depression improved in the combined therapy group at both the end of therapy and follow-up. Other significant effects were found in only one of the two therapy groups (positive symptoms; cognitive flexibility; uncontrollability of thoughts) or one of the two timepoints (end of therapy: PANSS general symptoms, anxiety, suicidal ideation, social functioning, resistance to voices; follow-up: power beliefs about voices, negative symptoms). There was no difference in costs between the groups. Conclusions: The only robust improvement was in depression. Nevertheless, there were further encouraging but modest improvements in both emotional and cognitive variables, in addition to psychotic symptoms

Orbitofrontal cortex, emotional decision-making and response to cognitive behavioural therapy for psychosis

Grey matter volume (GMV) in the orbitofrontal cortex (OFC) may relate to better response to cognitive behavioural therapy for psychosis (CBTp) because of the region's role in emotional decision-making and cognitive flexibility. This study aimed to determine the relation between pre-therapy OFC GMV or asymmetry and CBTp responsiveness and emotional decision-making as measured by the Iowa Gambling Task (IGT). Thirty patients received CBTp + standard care (CBTp+SC; 25 completers) for 6-8 months. All patients (before receiving CBTp) and 25 healthy participants underwent structural magnetic resonance imaging and performed the IGT. Patients' symptoms were assessed before and after therapy. Pre-therapy OFC GMV, measured using a region-of-interest approach, and IGT performance, measured as overall learning, attention to reward, memory for past outcomes and choice consistency, were comparable between patient and healthy groups. In the CBTp+SC group, greater OFC GMV was correlated with positive symptom improvement, specifically hallucinations and persecution. Greater rightward OFC asymmetry correlated with improvement in several negative and general psychopathology symptoms. Greater left OFC GMV was associated with lower IGT attention to reward. The findings suggest that greater OFC volume and rightward asymmetry, which maintain the OFC's function in emotional decision-making and cognitive flexibility, are beneficial for CBTp responsiveness