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SPONSORED BY CME LLC PSYCHIATRIC TIMES JUNE 2011

Relapse Prevention and Recovery in Patients With Psychosis: The Role of Psychiatric Rehabilitation
by Kim T. Mueser, PhD and Susan Gingerich, MSW

elapsesincluding symptom exacerbations and a deterioration in functioning that often requires hospitalizationcan be demoralizing for persons with a severe mental illness such as schizophrenia, bipolar disorder, or severe major depression. Relapses can interfere with independent living, work, and community adjustment; therefore, minimizing relapses is a common treatment goal. In fact, for many years the primary goal of treatment for these disorders was the prevention of

relapses and the successful maintenance of a stable clinical state. Although relapse prevention continues to be an important focus of treatment, stable clinical functioning is no longer a sufficient long-term treatment goal. Patients with major mental illnesses can achieve much more than just a stable clinical state; they can continue to grow as individuals and lead rewarding, productive, and meaningful lives, despite experiencing some symptoms or impairments.1 Because of the guiding vision of recovery and advances in pharmacological treatment and psychiatric rehabilitation, patients with severe mental illness now have

a greater potential than ever before to live productive, happy lives. We begin this article with a brief discussion of the concept of recovery, its meaning to persons with severe mental illness, and its importance for developing a therapeutic relationship with the patient. We discuss the relevance of relapse prevention to the long-term goal of recovery and summarize the stress-vulnerability model of severe mental illness, which provides a heuristic framework for preventing relapses. We then provide a definition of psychiatric rehabilitation and describe rehabilitation approaches that have direct or indirect effects on the prevention of relapses.

CREDITS: 1.5 RELEASE DATE: June 20, 2011 EXPIRATION DATE: June 20, 2012 FACULTY Kim T. Mueser, PhD, Dartmouth Psychiatric Research Center, Department of Psychiatry, Dartmouth Medical School Susan Gingerich, MSW, Private Practice, Narberth, Pa FACULTY DISCLOSURES Dr Mueser and Ms Gingerich have no relationships to disclose relating to the subject matter of this article. Applicable CME LLC staff have no relationships to disclose relating to the subject matter of this activity. This activity has been independently reviewed for balance. TARGET AUDIENCE This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, nurse practitioners, and other health care professionals who seek to improve their care for patients with schizophrenia. GOAL STATEMENT This activity will provide participants with an understanding of the importance of relapse prevention when treating schizophrenia in order for patients to maintain their qualify of life and functioning. ESTIMATED TIME TO COMPLETE The activity in its entirety should take approximately 90 minutes to complete.

LEARNING OBJECTIVES After completing this activity, participants should be able to: Better appreciate the concept of recovery Recognize the importance of developing a therapeutic relationship with the patient Understand the different rehabilitation approaches and how they can help prevent relapses Summarize the stress-vulnerability model of severe mental illness COMPLIANCE STATEMENT This activity is an independent educational activity under the direction of CME LLC. The activity was planned and implemented in accordance with the Essential Areas and policies of the ACCME, the Ethical Opinions/Guidelines of the AMA, the FDA, the OIG, and the PhRMA Code on Interactions with Healthcare Professionals, thus assuring the highest degree of independence, fair balance, scientific rigor, and objectivity. ACCREDITATION STATEMENT This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of CME LLC and Psychiatric Times. CME LLC is accredited by the ACCME to provide continuing medical education for physicians. CREDIT DESIGNATION CME LLC designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their

participation in the activity. Physician assistants, nurse practitioners, and nurses may participate in this educational activity and earn a certificate of completion, as AAPA, AANP, and ANCC accept AMA PRA Category 1 Credits through their reciprocity agreements. DISCLAIMER The opinions and recommendations expressed by faculty and other experts whose input is included in this activity are their own and do not necessarily reflect the views of the sponsors or supporter. Discussions concerning drugs, dosages, and procedures may reflect the clinical experience of the faculty or may be derived from the professional literature or other sources and may suggest uses that are investigational in nature and not approved labeling or indications. Activity participants are encouraged to refer to primary references or full prescribing information resources. METHOD OF PARTICIPATION Participants are required to read the entire article and to complete the posttest and evaluation to earn a certificate of completion. A passing score of 80% or better earns the participant 1.5 AMA PRA Category 1 Credits. A fee of $15 will be charged. Participants are allowed 2 attempts to successfully complete the activity. SPONSORED BY

To earn credit online, go to www.PsychiatricTimes.com/cme.

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A new vision of recovery In traditional terms, recovery refers to the absence of symptoms or characteristic impairments of an illness. For psychiatric disorders, this has usually meant the remission of significant psychiatric symptoms, accompanied by adequate psychosocial functioning in areas such as independent living and going to work or school. However, in recent years, the mental health consumer movement has argued for a more personally meaningful definition of recovery.2 For example, recovery has been defined as the development of new meaning and purpose in ones life as one grows beyond the catastrophic effects of mental illness.3 Another definition of recovery is the process in which people are able to live, work, learn, and participate fully in their communities.4 From these perspectives, recovery refers more to the reestablishment of ones life and sense of purpose than to recuperation from a disease. Recovery connotes the possibility of a future beyond having a severe mental illness. By assuming that everybody with a mental illness is capable of recovery in the sense of living a rewarding and meaningful life, psychiatrists and other mental health professionals can open up a dialogue with the patient aimed at exploring the concept of recovery. The clinician and patient can begin to identify goals that the patient would like to work toward in treatment. Establishing goals based on the patients vision of recovery can facilitate the development of a therapeutic relationship because the patient sees the mental health professional as invested in helping him or her achieve personal goals, which is a critical component of the working alliance. Recovery goals are primarily aimed at improving functioning and enjoyment of life, rather than just the maintenance of a stable clinical

It is widely accepted that patients with severe mental illness can play an active role in the management of and recovery from illness beyond just coping.
state. People are more easily motivated to work toward positive changes than they are to prevent negative things. However, once a recovery goal has been identified, patient motivation to work on relapse prevention can be harnessed by exploring how relapses could interfere with achieving the goal (eg, holding down a job, living independently). Thus, collaborative development of treatment goals based on an enlightened discussion of recovery can motivate the patient to improve the management of his illness. stress-vulnerability model to incorporate new perspectives on recovery as an outcome and the concept of recovery management skills. The expanded model is depicted in the Figure and is described below. Two biological factors can influence vulnerability and risk of relapse: substance abuse and medication. Alcohol or drug abuse is a potent precipitant of relapses and hospitalizations, whereas antipsychotic, mood-stabilizing, and antidepressant medications can reduce the risk of relapses.5-7 Biological vulnerability can also be increased by stress, such as normal or traumatic life events, exposure to high levels of interpersonal tension, or lack of meaningful structure.8-10 Coping skills and social support, however, can reduce the effects of stress on symptoms and relapses. The treatment implications of the traditional stress-vulnerability model are straightforward. The outcome of psychotic disorders can be improved through interventions that reduce psychobiological vulnerability or stress or that improve social support and coping skills. Increasing adherence to medication and reducing substance abuse can lower vulnerability and improve the course of the illness. Interventions that reduce stress in the environment and increase social support, such as family psychoeducation, can minimize relapses and improve functioning. Meaningful structured activities that are not too demanding can also reduce environmental stress. In addition, patients can be taught skills to enhance their ability to deal with internal sources of stress (eg, coping skills for anxiety, depression, persistent hallucinations), to handle external sources of stress (eg, social skills for managing interpersonal conflict), or to achieve personal goals (eg, social skills, problem-solving skills). It is widely accepted that patients with severe mental illness can play an active role in the management of and recovery from illness beyond just coping. Recovery management skills or strategies include setting and pursuing personally meaningful goals, learning about ones psychiatric disorder and its treatment, collaborating with professionals and significant others in shared decision making, and developing relapse prevention plans based on monitoring symptoms and taking rapid action at the first sign of worsening.11 These skills can reduce biological vulnerability
(Please see Psychiatric Rehabilitation, page 68)

Expanded stress-vulnerability model The stress-vulnerability model posits that the primary cause of severe mental illness is a psychobiological vulnerability, determined early in life by genetics and environmental insults (eg, obstetric complications, early life trauma), and is potentially precipitated by stress. Once a psychiatric disorder has developed, the course of the illness and the likelihood of relapses are determined by the interactions between biological and psychosocial factors. Here we have expanded the

Figure

Expanded stress-vulnerability model

Biological and psychosocial influences:

Alcohol and drug abuse

Medication adherence

Recovery management skillsa

Coping

Social support

Underlying factors:

Biological vulnerability

Stress

Outcomes:

Psychopathology Symptoms Relapses Hospitalizations

Recovery Work/school Social functioning Independent living Well-being

Recovery management: Pursuit of personal goals Understanding of mental illness Shared decision making Relapse prevention plans

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strategy to help manage the psychiatric disorder. In addition to providing the patient with basic information about the benefits and adverse effects of medication, and dispelling inaccurate beliefs about medication, the clinician can help the patient make a decision by listing and weighing the pros and cons of the medication. Once the person has made a decision to take medication, a variety of different strategies can be used to help him adhere to the regimen (Table 1). Relapse prevention plans can avert relapses

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and stress, as well as contribute to or reduce biological and psychosocial influences on those underlying factors, such as medication adherence or coping efforts. Moreover, new perspectives on recovery have shifted the emphasis away from the absence of psychopathology or impairment toward development of new meaning and sense of purpose in life, with functional goals as commonly desired recovery outcomes.4,12 Recovery outcomes are defined as the ability to go to work or school, sustain social relationships, live independently, and maintain well-being. While psychopathology can have an impact on recovery, so can recovery management skills, either directly or indirectly through improved illness management. Finally, social support can play a critical role in helping patients make progress toward their personal goals and recovery.

and reduce the severity of any that do occur.17 Relapses usually occur gradually over several weeks and are preceded by subtle early warning signs (such as difficulty in sleeping, confusion, or depression) or mild increases in symptoms. Rapid action (eg, temporarily increasing the dosage of medication) in response to such warning signs can reduce or forestall relapses. Family members or other significant persons who are involved in the development of a relapse prevention plan with the patient can make the

Table 1
Strategy

Strategies for facilitating adherence in patients who choose to take medication

Description

Behavioral tailoring

Incorporate taking of medication into the patients daily routine

Pill organizers  Help patient organize medication in a dispenser that has all the pills that need to be taken at one time Reminders to help patients take medication  Set alarm on cell phones and other electronic devices to remind the patient to take medication Reduce medication regimen complexity  Reduce the number of medications and how often they must be taken Engage social support  Caregivers can remind the patient when it is time to take medication Long-acting depot medications  With injectable depot antipsychotics, patients do not need to remember to take medication every day

Illness self-management Psychiatric rehabilitation is the systematic application of psychosocial interventions designed to improve the symptomatic and functional course of a major psychiatric disorder.13,14 A wide range of psychiatric rehabilitation methods have been shown to be effective for severe mental illnesses. Many psychiatric rehabilitation methods focus on improving the persons skills or competence, providing environmental supports, or using a combination of both. For example, learning illness self-management or social skills methods improves patient competence, family psychoeducation provides a more knowledgeable and supportive family milieu, and supported employment combines improved patient skills with environmental supports to facilitate work in the community. There are several approaches to teaching illness self-management skills. The strategies described below are incorporated into the Illness Management and Recovery program, a curriculum-based program to help patients identify and work toward personal recovery goals. Critical information includes the patients psychiatric diagnosis, common symptoms, the course of the disorder, the stress-vulnerability model, medications, and psychiatric rehabilitation methods. When educating patients, it is important to create a sense of hope and optimism about their ability to manage the psychiatric illness and achieve personal goals.15 Psychoeducation is most effective when the clinician engages the patient in an interactive manner, uses language that the patient feels comfortable with, and pauses frequently to ask questions to help the patient relate the information to his own experiences and to evaluate his understanding of the information. Educational handouts are also useful for teaching patients about the disorder. Medication nonadherence is a major contributor to relapses and hospitalizations; therefore improving adherence is a common goal of illness self-management programs.16 However, before efforts to improve adherence can be undertaken, it is important to engage the patient in making an informed decision about taking medication as a

Table 2

Developing a relapse prevention plan

Involve a caregiver when developing the relapse prevention plan with the patient  Explain that most relapses occur gradually over time and that developing a relapse prevention plan can prevent or reduce the severity of relapses and rehospitalizations Explain that preventing relapses may be helpful in achieving personal goals  Discuss situations that have precipitated relapses in the past (eg, stressful events, medication nonadherence, alcohol or drug abuse)  Focus on the most recent relapses and identify 2 or 3 early warning signs or mild symptom increases that preceded the full-blown relapse Discuss how to monitor for early warning signs or mild symptom increases Decide on what the patients response will be to early warning signs or mild symptom increases Write the plan down  Rehearse the relapse prevention plan with the patient (and significant others if applicable) and make any modifications as needed Include a copy of the plan in the patients record, and give copies to all relevant people In case of a relapse, review the plan and modify as needed

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oriented rather than avoidance-based strategies.19 Examples of common coping strategies for persistent symptoms are summarized in Table 3.

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plan even more effective. The steps for developing a relapse prevention plan are outlined in Table 2. (Standard forms for developing relapse prevention plans are available from a variety of sources.11,15) Persistent psychiatric symptoms, such as hallucinations, depression, anxiety, and negative symptoms are distressing and interfere with patients functioning and their ability to achieve personal goals. However, patients often develop coping strategies for dealing with symptoms, which can be systematically taught to other patients to bolster coping skills.18 A wide range of coping strategies can be taught for each persistent symptom using a combination of modeling (demonstrating) the skill in role play, engaging the patient in practicing the skill, developing a home assignment for the patient to practice the skill on his own, and refining the skill as needed based on the patients experience using it. Better coping effectiveness and adjustment are associated with the use of more coping strategies, especially problem solving

Other evidence-based psychiatric rehabilitation programs Training in illness self-management most explicitly targets the prevention of relapses and teaches other personal management skills to help patients make progress toward their personal recovery goals. Other psychiatric rehabilitation programs include family psychoeducation, integrated treatment for co-occurring substance abuse, social skills training, supported employment, cognitivebehavioral therapy for psychosis, and cognitive remediation. Family psychoeducation Many patients with severe mental illness have regular contact with their family members, who may provide a wide range of emotional and instrumental support and are ideally suited to help manage the patients treatment plan. Unfortu-

nately, these caregivers often lack information about psychiatric disorders, which can contribute to stress and precipitate relapses.20 In addition, families often do not have a working relationship with the patients treatment team, which makes it difficult for them to support the teams treatment recommendations. Family psychoeducation provides caregivers with accurate information about the nature of the patients psychiatric disorder and the principles of its treatment so that they can become active collaborators.21 A variety of different single- and multiple-family programs have been developed to educate families (including the patient) about mental illness, to actively involve caregivers in the treatment process, and to teach them strategies for reducing stress in family relationships.22,23 Relapse prevention is typically incorporated into family psychoeducation programs.

Table 3
Symptom

Examples of coping strategies for persistent symptoms

Coping strategies

Depression Hallucinations Anxiety Sleep problems

Schedule pleasant events Positive self-talk Cognitive restructuring to challenge inaccurate thoughts and beliefs Exercise Distraction Positive self-talk Acceptance Cognitive restructuring to challenge inaccurate beliefs about omnipotence of voices Prayer Active involvement in work or recreational activities Learn relaxation skills Gradual exposure to feared but safe situations or stimuli Positive self-talk Cognitive restructuring to challenge inaccurate beliefs about feared but safe situations Role play of anxiety-producing situations in advance to get comfortable and improve skills Set a specific time to go to bed and to wake up Avoid caffeine after 5 pm Avoid napping Create a relaxing bedtime routine Avoid stimulating activities (eg, watching violent television) Get regular exercise

Integrated treatment for cooccurring substance use disorders In patients with severe mental illness, the rates of co-occurring alcohol and drug use disorders are high. Approximately 50% of these patients have substance abuse or dependence over their lifetime compared with 15% of persons in the general population.24,25 Substance abuse is a major contributor to relapse and hospitalizations as well as other negative outcomessuch as housing problems, depression and demoralization, and medical and legal problems. Historically, efforts to treat co-occurring disorders with separate mental health and substance abuse treatment systems proved ineffective. Affected patients often had difficulty with accessing both services, either because of poor motivation or because of eligibility barriers.26 To address these problems, integrated treatment programs have been developed recently and validated empirically.27-29 A core principle is that both mental health and substance use problems are concurrently treated by the same clinician or treatment team. Research on integrated treatment for cooccurring disorders supports the efficacy of these programs in reducing substance abuse relative to traditional, nonintegrated treatment methods.30,31 With the reduction of substance use and abstinence comes a reduction in the number of re lapses and hospitalizations and improved psychosocial functioning.32 Social skills training Persons who have severe mental illness are frequently very interested in improving their social relationshipsincluding friendships and close interpersonal relationships. Social skills training is a systematic approach used to improve social functioning; usually, it is delivered in a group format.33 Training methods involve role playing, positive and corrective feedback to shape more effective skills, and collaborative development of home assignments to practice social skills. Additional strategies to facilitate the generalization of skills from training sessions to real-world community settings are typically employed in social skills training. These may include in vivo
(Please see Psychiatric Rehabilitation, page 70)

 For difficulty with falling asleep or falling back to sleep after waking in the night, get out of bed and do pre-bedtime activity (eg, read) until tired again

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tioning and well-being. Over the past 2 decades, there have been major advances in the clinical application of CBT for psychosis. CBT helps reduce both psychotic and negative symptoms and improves psychosocial functioning.46 In addition to directly reducing vulnerability to relapses, CBT may also help patients achieve personal goals, such as having close social relationships or getting a job, which can indirectly lower the risk of relapse.
References

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practice and collaborating with natural support persons (ie, indigenous supporters) to help patients practice and use skills on their own.34 Early research on social skills training was hampered by methodological limitations; lack of attention to the generalization of social skills; and a focus on symptoms, relapse, and social skills but not on functional outcomes. Most reviews of early research concluded that training improved social skills, but it did not improve symptoms or relapse rates.35-37 More recently, with the benefit of more rigorous controlled studies, 2 meta-analyses suggest that social skills training improves social skills, quality of social relationships, and community functioning.38,39 Based on the stress-vulnerability model, social skills training would also be expected to have an indirect effect on the course of the psychiatric disorder through the strengthening of social supports. Indeed, research bears out this hypothesis. Social skills training was also modestly effective in reducing symptom severity and in preventing relapses.38,39

Supported employment Competitive work is a common goal for many patients with severe psychiatric disorders. There are numerous benefits, including increased selfesteem and financial standing, reduced symptoms, and an improved sense of purpose. In recent years, supported employment has become a major focus of research on vocational rehabilitation for persons with psychiatric disorders. Supported employment focuses on helping patients get competitive jobs in the community rather than sheltered or transitional work, and then it focuses on providing ongoing supports to help them succeed at the workplace or transition to another job.40,41 The preponderance of controlled research on supported employment has evaluated the Individual Placement and Support (IPS) model, which has both a manual and a fidelity scale.41,42 Research on the IPS model demonstrates that this approach produces better competitive work outcomes than other vocational models.43 Long-term employment is associated with a reduction in the use of mental health services.44 Aside from the fact that work is associated with modest benefits in improved clinical functioning and well-being, for many patients the goal of getting and keeping a competitive job serves as an important motivating factor to learn how to prevent relapses and the disruptive effects associated with them. Cognitive-behavioral therapy for psychosis Persistent psychotic symptoms are present in 25% to 40% of patients who have schizophrenia, are a major source of distress and functional impairment, and can increase patients vulnerability to relapses.45 Cognitive-behavioral therapy (CBT) focuses on reducing the severity and distress of psychotic symptoms as well as other symptoms that can interfere with func-

Cognitive remediation Cognitive impairment is a common feature of schizophrenia and other severe psychiatric disorders. Impaired cognitive functioning is strongly related to psychosocial dysfunction in areas such as independent living skills and work.47 Moreover, patients who are cognitively impaired tend to benefit less from psychiatric rehabilitation programs.48 Therefore, efforts to improve cognitive functioning have been the focus of considerable research. Cognitive remediation is a broad set of approaches aimed at improving cognitive functioning and reducing the effects of cognitive impairment on poor psychosocial functioning. Such remediation is aimed at systematically enhancing cognitive skills through a combination of extensive practice and teaching more effective cognitive skills, (ie, teaching compensatory strategies). Many programs include cognitive enhancement techniques as well as compensatory strategies. Cognitive remediation has been found to improve not only cognitive functioning but also functional outcomes when it is provided in combination with another psychiatric rehabilitation program, such as vocational rehabilitation or skills training.49,50 Cognitive remediation also has modest beneficial effects on symptoms. Thus, cognitive remediation can provide greater benefits from psychiatric rehabilitation and help patients achieve their recovery goals, which can indirectly reduce vulnerability to relapses. In addition, cognitive remediation has the potential to reduce the number of relapses and hospitalizations by providing a stress management plan and a relapse prevention plan. Summary and conclusions The primary treatment goal for patients with severe mental illness is symptom remission and an improved quality of life. Psychiatric rehabilitation technology has been shown to be effective in improving symptomatic and functional outcomes by teaching relapse prevention skills to patients and their caregivers. Relapse prevention interventions are most effective when they are provided in the context of a therapeutic relationship that is aimed at helping patients achieve personally valued goals. The patients motivation to achieve the set goals can be harnessed to reduce vulnerability to relapses. In addition to interventions that directly target relapse prevention, psychiatric rehabilitation approaches can indirectly reduce vulnerability to relapses by improving areas of functioning such as interpersonal relationships, long-term competitive employment, burden of psychotic symptoms, and cognitive functioning.

1. Roe D, Chopra M. Beyond coping with mental illness: toward personal growth. Am J Orthopsychiatry. 2003;73:334-344. 2. Bellack AS. Scientific and consumer models of recovery in schizophrenia: concordance, contrasts, and implications. Schizophr Bull. 2006;32:432-442. 3. Anthony WA. Recovery from mental illness: the guiding vision of the mental health service system in the 1990s. Psychosoc Rehabil J. 1993;16:11-23. 4. Presidents New Freedom Commission on Mental Health. Achieving the Promise: Transforming Mental Health Care in America: Final Re port. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2003. DHHS publication SMA-03-3832. 5. Drake RE, Brunette MF. Complications of severe mental illness related to alcohol and other drug use disorders. In: Galanter M, ed. Recent Developments in Alcoholism. Vol 14. New York: Plenum Publishing Company; 1998:285-299. 6. Linszen DH, Dingemans PM, Lenior ME. Cannabis abuse and the course of recent-onset schizophrenic disorders. Arch Gen Psychiatry. 1994;51:273-279. 7. Schatzberg AF, Cole JO, DeBattista C. Manual of Clinical Psycho pharmacology. 6th ed. Washington, DC: American Psychiatric Publishing; 2007. 8. Bebbington PE, Kuipers L. Life events and social factors. In: Kavanagh DJ, ed. Schizophrenia: An Overview and Practical Handbook. London: Chapman & Hall; 1992:126-144. 9. Butzlaff RL, Hooley JM. Expressed emotion and psychiatric relapse: a meta-analysis. Arch Gen Psychiatry. 1998;55:547-552. 10. Wong SE, Terranova MD, Bowen L, et al. Providing independent recreational activities to reduce stereotypic vocalizations in chronic schizophrenics. J Appl Behav Anal. 1987;20:77-81. 11. Gingerich S, Mueser KT. Illness Management and Recovery Imple mentation Resource Kit. Rev ed. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration; 2010. 12. Davidson L. Living Outside Mental Illness: Qualitative Studies of Recovery in Schizophrenia. New York: New York University Press; 2003. 13. Corrigan PW, Mueser KT, Bond GR, et al. The Principles and Practice of Psychiatric Rehabilitation: An Empirical Approach. New York: Guilford Press; 2008. 14. Liberman RP. Recovery from Disability: Manual of Psychiatric Rehabilitation. Washington, DC: American Psychiatric Publishing; 2008. 15. Brown C, ed. Recovery and Wellness: Models of Hope and Em powerment for People with Mental Illness. New York: Haworth Press; 2001. 16. Nos M, Barbui C, Gray R, Tansella M. Clinical interventions for treatment non-adherence in psychosis: meta-analysis. Br J Psychiatry. 2003;183:197-206. 17. Herz MI, Lamberti JS, Mintz J, et al. A program for relapse prevention in schizophrenia: a controlled study. Arch Gen Psychiatry. 2000; 57:277-283. 18. Breier A, Strauss JS. Self-control of psychotic disorders. Arch Gen Psychiatry. 1983;40:1141-1145. 19. Yanos PT, West ML, Smith SM. Coping, productive time use, and negative mood among adults with severe mental illness: a daily diary study. Schizophr Res. 2010;124:54-59. 20. Hooley JM. Expressed emotion and relapse of psychopathology. Annu Rev Clin Psychol. 2007;3:329-352. 21. Lefley H. Family Psychoeducation for Serious Mental Illness. New York: Oxford University Press; 2009. 22. McFarlane WR. Multifamily Groups in the Treatment of Severe Psy chiatric Disorders. New York: Guilford Press; 2002. 23. Mueser KT, Glynn SM. Behavioral Family Therapy for Psychiatric Disorders. 2nd ed. Oakland, CA: New Harbinger; 1999. 24. Mueser KT, Yarnold PR, Rosenberg SD, et al. Substance use disorder in hospitalized severely mentally ill psychiatric patients: prevalence, correlates, and subgroups. Schizophr Bull. 2000;26:179-192. 25. Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA. 1990;264:2511-2518. 26. Ridgely MS, Goldman HH, Willenbring M. Barriers to the care of persons with dual diagnoses: organizational and financing issues.

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34. Glynn SM, Marder SR, Liberman RP, et al. Supplementing clinicbased skills training with manual-based community support sessions: effects on social adjustment of patients with schizophrenia. Am J Psy chiatry. 2002;159:829-837. 35. Bellack AS. Skills training for people with severe mental illness. Psychiatr Rehabil J. 2004;27:375-391. 36. Benton MK, Schroeder HE. Social skills training with schizophrenics: a meta-analytic evaluation. J Consult Clin Psychol. 1990;58:741747. 37. Dilk MN, Bond GR. Meta-analytic evaluation of skills training research for individuals with severe mental illness. J Consult Clin Psy chol. 1996;64:1337-1346. 38. Kurtz MM, Mueser KT. A meta-analysis of controlled research on social skills training for schizophrenia. J Consult Clin Psychol. 2008;76:491-504. 39. Pfammatter M, Junghan UM, Brenner HD. Efficacy of psychological therapy in schizophrenia: conclusions from meta-analyses. Schizophr Bull. 2006;32(suppl 1):S64-S80. 40. Becker DR, Bond GR, eds. Supported Employment Implementation Resource Kit. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration; 2004. 41. Becker DR, Drake RE. A Working Life for People with Severe Men tal Illness. New York: Oxford University Press; 2003. 42. Bond GR, Becker DR, Drake RE, Vogler KM. A fidelity scale for the

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Schizophr Bull. 1990;16:123-132. 27. Bellack AS, Bennet ME, Gearon JS. Behavioral Treatment for Sub stance Abuse in People with Serious and Persistent Mental Illness: A Handbook for Mental Health Professionals. New York: Taylor and Francis; 2007. 28. Carey KB, Leontieva L, Dimmock J, et al. Adapting motivational interventions for comorbid schizophrenia and alcohol use disorders. Clin Psychol. 2007;14:39-57. 29. Mueser KT, Noordsy DL, Drake RE, Fox L. Integrated Treatment for Dual Disorders: A Guide to Effective Practice. New York: Guilford Press; 2003. 30. Drake RE, ONeal EL, Wallach MA. A systematic review of psychosocial research on psychosocial interventions for people with cooccurring severe mental and substance use disorders. J Subst Abuse Treat. 2008;34:123-138. 31. Kavanagh DJ, Mueser KT. Current evidence on integrated treatment for serious mental disorder and substance misuse. J Norwegian Psychological Assoc. 2007;44:618-637. 32. Xie H, McHugo GJ, Drake RE. Subtypes of clients with serious mental illness and co-occurring disorders: latent-class trajectory analysis. Psychiatr Serv. 2009;60:804-811. 33. Bellack AS, Mueser KT, Gingerich S, Agresta J. Social Skills Training for Schizophrenia: A Step-by-Step Guide. 2nd ed. New York: Guilford Press; 2004.

individual placement and support model of supported employment. Rehabil Counsel Bull. 1997;40:265-284. 43. Bond GR, Drake RE, Becker DR. An update on randomized controlled trials of evidence-based supported employment. Psychiatr Rehabil J. 2008;31:280-290. 44. Bush PW, Drake RE, Xie H, et al. The long-term impact of employment on mental health service use and costs for persons with severe mental illness. Psychiatr Serv. 2009;60:1024-1031. 45. Racenstein JM, Harrow M, Reed R, et al. The relationship between positive symptoms and instrumental work functioning in schizophrenia: a 10-year follow-up study. Schizophr Res. 2002;56:95-103. 46. Wykes T, Steel C, Everitt B, Tarrier N. Cognitive behavior therapy for schizophrenia: effect sizes, clinical models and methodological rigor. Schizophr Bull. 2008;34:523-537. 47. Green MF. Cognitive impairment and functional outcome in schizophrenia and bipolar disorder. J Clin Psychiatry. 2006;67(suppl 9):3-8. 48. McGurk SR, Mueser KT. Cognitive functioning, symptoms, and work in supported employment: a review and heuristic model. Schizophr Res. 2004;70:147-173. 49. McGurk SR, Twamley EW, Sitzer DI, et al. A meta-analysis of cognitive remediation in schizophrenia. Am J Psychiatry. 2007;164:17911802. 50. Wykes T, Huddy V, Cellard C, et al. A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes. Am J Psychiatry. 2011 Mar 15; [Epub ahead of print]. r

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1.  According to the stress-vulnerability model, which of the following is the primary cause of severe mental illness? A. Brain trauma B. Psychobiological vulnerability C. Adrenoleukodystrophy D. None of the above 2.  Which of the following can affect the risk of relapse? A. Substance abuse B. Psychopharmacology C. Social skills D. All of the above 3.  Which of the following statements is not true? A.  Goal setting with patients will help motivate them to take part in managing their treatment B.  Family/caregiver psychoeducation plays no role in preventing relapse in patients with severe mental illness C.  Monitoring for early warning signs and symptom increases is part of the relapse prevention plan D.  Problem solvingoriented coping strategies have been found to be more effective than avoidance-based coping strategies

4.  Approximately what percentage of patients with severe mental illness will have co-occurring alcohol or drug use disorders over their lifetime? A. 15% B. 25% C. 50% D. None of the above 5.  Efforts to treat co-occurring disorders with separate mental health and substance use treatments have been found to be most effective. A. True B. False 6.  Which of the following models produces better competitive work outcomes? A. Supported work program B. Individual Placement and Support model C. Assertive community treatment vocational model 7.  What percentage of patients with schizophrenia have persistent psychotic symptoms? A. 10% to 15%

B. 20% to 40% C. 25% to 40% D. 30% to 50% 8.  Cognitive-behavioral therapy has been shown to improve psychosocial functioning. A. True B. False 9.  The aim of cognitive remediation is to: A. Improve cognitive function B. Improve psychosocial skills C. Improve symptoms D. All of the above E. None of the above 10.  Recovery outcomes in patients with schizophrenia are gauged by remission of symptoms. A. True B. False

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