State of the art of integrated therapy approaches in the treatment of schizophrenia: empirical evidence and clinical relevance

Objective: Integrated behavior therapy approaches are defined by the combination of behavioral and or cognitive interventions targeting neurocognition combined with other goal-oriented treatment targets such as social cognition, social skills, or educational issues. The Integrated Psychological Therapy Program (IPT) represents one of the very first behavior therapy approaches combining interventions of neurocognition, social cognition, and social competence. This comprehensive group-based bottom-up and top-down approach consists of five subprograms, each with incremental steps. IPT has been successfully implemented in several countries in Europe, America, Australia and in Asia. IPT worked as a model for some other approaches designed in the USA. IPT was undergone two further developments: based on the social competence part of IPT, the three specific therapy programs focusing residential, occupational or recreational topics were developed. Recently, the cognitive part of INT was rigorously expanded into the Integrated Neurocognitive Therapy (INT) designed exclusively for outpatient treatment: INT includes interventions targeting all neurocognitive and social cognitive domains defined by the NIMH-MATRICS initiative. These group and partially PC-based exercises are structured into four therapy modules, each starting with exercises on neurocognitive domains followed by social cognitive targets. Efficacy: The evidence of integrated therapy approaches and its advantage compared to of one-track interventions was becoming a discussion tool in therapy research as well as in mental health systems. Results of meta-analyses support superiority of integrated approaches compared to one-track interventions in more distal outcome areas such as social functioning. These results are in line with the large body of 37 independent IPT studies in 12 countries. Moreover, IPT research indicates the maintenance of therapy effects after the end of therapy and some evidence generalization effects. Additionally, the international randomized multi-center study on INT with 169 outpatients strongly supports the successful therapy of integrated therapy in proximal and distal outcome such as significant effects in cognition, functioning and negative symptoms. Clinical implication: therapy research as well as expert’s clinical experience recommends integrated therapy approaches such as IPT to be successful agents within multimodal psychiatric treatment concepts. Finally, integrated group therapy based on cognitive remediation seems to motivate and stimulate schizophrenia inpatients and outpatients to more successful and independent life also demanded by the recovery movement.

The brain’s default state interacts with working memory processes in a complex and load-dependent manner

Recently, many studies about a network active during rest and deactivated during tasks emerged in the literature: the default mode network (DMN). Spatial and temporal DMN features are important markers for psychiatric diseases. Another prominent indicator of cognitive functioning, yielding information about the mental condition in health and disease, is working memory (WM) processing. In EEG studies, frontal-midline theta power has been shown to increase with load during WM retention in healthy subjects. From these findings, the conclusion can be drawn that an increase in resting state DMN activity may go along with an increase in theta power in high-load WM conditions. We followed this hypothesis in a study on 17 healthy subjects performing a visual Sternberg WM task. The DMN was obtained by a BOLD-ICA approach and its dynamics represented by the percent-strength during pre-stimulus periods. DMN dynamics were temporally correlated with EEG theta spectral power from retention intervals. This so-called covariance mapping yielded the spatial distribution of the theta EEG fluctuations associated with the dynamics of the DMN. In line with previous findings, theta power was increased at frontal-midline electrodes in high- versus low-load conditions during early WM retention. However, load-dependent correlations of DMN with theta power resulted in primarily positive correlations in low-load conditions, while during high-load conditions negative correlations of DMN activity and theta power were observed at frontal-midline electrodes. This DMN-dependent load effect reached significance during later retention. Our results show a complex and load-dependent interaction of pre-stimulus DMN activity and theta power during retention, varying over the course of the retention period. Since both, WM performance and DMN activity, are markers of mental health, our results could be important for further investigations of psychiatric populations.

The brain’s pre-stimulus default state interacts with working memory in a load-dependent manner

Recently, multiple studies showed that spatial and temporal features of a task-negative default mode network (DMN) (Greicius et al., 2003) are important markers for psychiatric diseases (Balsters et al., 2013). Another prominent indicator of cognitive functioning, yielding information about the mental condition in health and disease, is working memory (WM) processing. In EEG and MEG studies, frontal-midline theta power has been shown to increase with load during WM retention in healthy subjects (Brookes et al., 2011). Negative correlations between DMN activity and theta amplitude have been found during resting state (Jann et al., 2010) as well as during WM (Michels et al., 2010). Likewise, WM training resulted in higher resting state theta power as well as increased small-worldness of the resting brain (Langer et al., 2013). Further, increased fMRI connectivity between nodes of the DMN correlated with better WM performance (Hampson et al., 2006). Hence, the brain’s default state might influence it’s functioning during task. We therefore hypothesized correlations between pre-stimulus DMN activity and EEG-theta power during WM maintenance, depending on the WM load. 17 healthy subjects performed a Sternberg WM task while being measured simultaneously with EEG and fMRI. Data was recorded within a multicenter-study: 12 subjects were measured in Zurich with a 64-channels MR-compatible system (Brain Products) in a 3T Philips scanner, 5 subjects with a 96-channel MR-compatible system (Brain Products) in a 3T Siemens Scanner in Bern. The DMN components was obtained by a group BOLD-ICA approach over the full task duration (figure 1). The subject-wise dynamics were obtained by back-reconstructed onto each subject’s fMRI data and normalized to percent signal change values. The single trial pre-stimulus-DMN activation was then temporally correlated with the single trial EEG-theta (3-8 Hz) spectral power during retention intervals. This so-called covariance mapping (Jann et al., 2010) yielded the spatial distribution of the theta EEG fluctuations during retention associated with the dynamics of the pre-stimulus DMN. In line with previous findings, theta power was increased at frontal-midline electrodes in high- versus low-load conditions during early WM retention (figure 2). However, correlations of DMN with theta power resulted in primarily positive correlations in low-load conditions, while during high-load conditions negative correlations of DMN activity and theta power were observed at frontal-midline electrodes. This DMN-dependent load effect reached significance in the middle of the retention period (TANOVA, p<0.05) (figure 3). Our results show a complex and load-dependent interaction of pre-stimulus DMN activity and theta power during retention, varying over time. While at a more global, load-independent view pre-stimulus DMN activity correlated positively with theta power during retention, the correlation was inversed during certain time windows in high-load trials, meaning that in trials with enhanced pre-stimulus DMN activity theta power decreases during retention. Since both WM performance and DMN activity are markers of mental health our results could be important for further investigations of psychiatric populations.

Disentangling mental imagery and perceptual expectation

Mental imagery and perception are thought to rely on similar neural circuits, and many recent behavioral studies have attempted to demonstrate interactions between actual physical stimulation and sensory imagery in the corresponding sensory modality. However, there has been a lack of theoretical understanding of the nature of these interactions, and both interferential and facilitatory effects have been found. Facilitatory effects appear strikingly similar to those that arise due to experimental manipulations of expectation. Using a self-motion discrimination task, we try to disentangle the effects of mental imagery from those of expectation by using a hierarchical drift diffusion model to investigate both choice data and response times. Manipulations of expectation are reasonably well understood in terms of their selective influence on parameters of the drift diffusion model, and in this study, we make the first attempt to similarly characterize the effects of mental imagery. We investigate mental imagery within the computational framework of control theory and state estimation. • Mental imagery and perception are thought to rely on similar neural circuits; however, on more theoretical grounds, imagery seems to be closely related to the output of forward models (sensory predictions). • We reanalyzed data from a study of imagined self-motion. • Bayesian modeling of response times may allow us to disentangle the effects of mental imagery on behavior from other cognitive (top-down) effects, such as expectation.

Diagnosing the Prodromal State of Alzheimer's Disease

Mild Cognitive Impairment- Amnestic Subtype (MCIa) is a putative prodromal stage of Alzheimer’s Disease (AD) characterized by focal deficits in episodic verbal memory. Less is known about relative deficits in visuospatial learning, although there is ample evidence indicating involvement of the hippocampus in visuospatial learning, as well as hippocampal degeneration in early AD. The aim of this study was to better characterize the components of working memory dysfunction in people with MCIa to increase the ability to reliably diagnose this disease. Fifty-six elderly adults diagnosed with MCIa and 94 healthy elderly completed a hidden maze learning task. Results indicated similar functioning between groups on measures of reasoning, problem solving, and accuracy. However, MCIa subjects were less efficient at learning the hidden path, making more errors per second on average (Cohen’s d= -.78) and requiring a longer time to complete the maze (Cohen’s d=.77). The learning curve between the first two trials was four times as steep for healthy elderly compared to MCIa (slopes = 4.9 vs. 1.24, respectively), indicating that MCIa subjects exhibited relative difficulty in holding and making effective use of an internal spatial map in order to improve performance. Our results suggest that MCIa patients have focal deficits in visuospatial working memory, with relative preservation of functioning on other more global measures of cognitive functioning. This particular pattern of results may be specific to the amnestic variant of MCI.

Medial prefrontal cortex and self-referential mental activity: Relation to a default mode of brain function

Medial prefrontal cortex (MPFC) is among those brain regions having the highest baseline metabolic activity at rest and one that exhibits decreases from this baseline across a wide variety of goal-directed behaviors in functional imaging studies. This high metabolic rate and this behavior suggest the existence of an organized mode of default brain function, elements of which may be either attenuated or enhanced. Extant data suggest that these MPFC regions may contribute to the neural instantiation of aspects of the multifaceted “self.” We explore this important concept by targeting and manipulating elements of MPFC default state activity. In this functional magnetic resonance imaging (fMRI) study, subjects made two judgments, one self-referential, the other not, in response to affectively normed pictures: pleasant vs. unpleasant (an internally cued condition, ICC) and indoors vs. outdoors (an externally cued condition, ECC). The ICC was preferentially associated with activity increases along the dorsal MPFC. These increases were accompanied by decreases in both active task conditions in ventral MPFC. These results support the view that dorsal and ventral MPFC are differentially influenced by attentiondemanding tasks and explicitly self-referential tasks. The presence of self-referential mental activity appears to be associated with increases from the baseline in dorsal MPFC. Reductions in ventral MPFC occurred consistent with the fact that attention-demanding tasks attenuate emotional processing. We posit that both self-referential mental activity and emotional processing represent elements of the default state as represented by activity in MPFC. We suggest that a useful way to explore the neurobiology of the self is to explore the nature of default state activity.

Saúde mental e os novos paradigmas de cidadania e inclusão social na sociedade contemporânea

Este estudo tem por objetivo analisar as categorias de cidadania e inclusão social na política de desinstitucionalização nos sujeitos em sofrimento psíquico diante do processo de individualização na teoria social contemporânea. Assume como hipótese que a saída do hospital psiquiátrico por si só não garante a inclusão social e nem o livre exercício da cidadania. Considerado o objetivo desta pesquisa, optou-se por fazer uma pesquisa bibliográfica como procedimento metodológico. O material de estudo foi dividido em três conjuntos: (1) 56 artigos científicos, visando a compreender a visão da academia; (2) um conjunto de legislação, composto de 10 leis que implementaram a política de desinstitucionalização no Brasil e a reforma dos serviços de saúde psiquiátrica, visando a compreender as ações do Estado; (3) quatro Relatórios Finais das quatro Conferências Nacionais de Saúde Mental, para também compreender a participação da sociedade civil. Para a análise do material, utilizou-se uma combinação de duas técnicas complementares: leitura bibliográfica com a análise de conteúdo. Dentre os vários processos que caracterizam a sociedade contemporânea, optou-se por analisar a individualização que impacta nas formas de exercício da cidadania e na inclusão social. Na análise dos resultados da categoria de cidadania foram identificadas associações em relação à interdição civil, liberdade, moradia, saúde, trabalho, educação e participação política. Relacionadas à categoria de inclusão social foram identificadas as referências à família, estigma, laços sociais, autonomia, contratualidade e trabalho. Os resultados obtidos indicam que o campo da saúde mental não está em completa consonância com as transformações da sociedade contemporânea, o que provoca um descolamento da realidade social da própria politica de desinstitucionalização e, portanto, maior dificuldade para a efetiva inclusão social e o exercício da cidadania desses indivíduos.

Establishing Culturally Sensitive Therapeutic Communities in Ghana for Individuals with Severe and Persistent Mental Illnesses

This paper makes a proposal for the establishment of therapeutic communities for people with severe and persistent mental illnesses in Ghana. It discusses the history and features of therapeutic communities, as well as the elements that make it compatible with the agenda of the new 2012 Ghana mental health bill. This paper also discusses the present state of mental health care in this West African country and how the establishment of therapeutic communities will promote recovery of people with severe and persistent mental illness, and change the perception of chronic mental illness in Ghana. A discussion of potential modifications of the therapeutic community is offered as well as justifications for maintaining other structural aspects should this establishment materialize in Ghana. The costs of setting up therapeutic communities in this third world country are addressed with the offered conclusion that costs far outweigh the benefits. Finally, given the endeavor of the proposed therapeutic communities to assist in deinstitutionalization of care, cautions are made in this paper to ensure that the trends experienced in the United States with deinstitutionalization are not replicated in Ghana. A proposal is made in the conclusion for Ghana to move past therapeutic communities when developmentally able- to community mental health centers which were in part established to account for some of the fallouts of deinstitutionalization by providing a comprehensive and extensive range of services for people with severe and persistent mental illness.

Relación entre el número de horas de cuidado informal y el estado de salud mental de las personas cuidadoras

Fundamento: La salud mental de las personas cuidadoras se ve perjudicada por las tareas de cuidado. Son necesarios estudios que especifiquen la influencia de diversas variables en la asociación entre cuidado informal y salud mental. El objetivo del trabajo es analizar los efectos del tiempo dedicado al cuidado informal en la salud mental por sexo según el tipo de personas dependientes. Métodos: Los datos que se utilizaron fueron los de la Encuesta Nacional de Salud 2006, cuya muestra estaba compuesta por 29.478 participantes. Variables: salud mental (GHQ-12), tiempo de cuidado, edad, clase social y apoyo funcional (Duke-UNC). Se realizó análisis de regresión logística para determinar la probabilidad de contar con mala salud mental según horas de cuidado, ajustado por edad, clase social y apoyo funcional. Resultados: Las mujeres presentan peor salud mental a partir de 97 horas semanales en el cuidado a menores (OR=1,372), de 25 horas en el cuidado a personas mayores de 74 años (OR=1,602 entre 25 y 48 horas; OR=1,467 49-96h; OR=1,874 97-168h) y cuando dedican alguna hora al cuidado de personas adultas con discapacidad (OR=1,996 0-24h; OR=2,507 25-48h; OR=3,016 49-96h; OR=1,651 97-168h). Los varones muestran deterioro de la salud psicológica cuando dedican un elevado número de horas al cuidado de personas mayores de 74 años (OR=2,810 97168h.) y personas con discapacidad (OR=3,411 97-168h.) y cuando dedican de 0 a 24h al cuidado de menores (OR=1,595). Conclusiones: El efecto del número de horas de cuidado en la salud mental de las personas cuidadoras está influido por el tipo de persona dependiente y por el sexo de la persona cuidadora.

State plan profiles, 1979-1980.

Mode of access: Internet.

The state and territorial guide to substance abuse prevention in declared disasters.

"Printed 1997"--T.p. verso.

State methadone treatment guidelines /

"Under purchase order number 91MF358084 and under contract number 270-91-004"--T.p. verso.

Federal and State laws pertaining to methadone /

Mode of access: Internet.

Drug abuse information, education, and rehabilitation programs supported by State health agencies and voluntary organizations.

Mode of access: Internet.