Schizophrenia is characterized by deficits in work and social functioning. The deficits in work functioning are particularly sobering. Reviews of the literature indicate that approximately 65% to 90% of persons with severe mental illness (SMI) are chronically unemployed. These figures are particularly discouraging given the importance of employment to the personal and clinical well-being of persons with SMI. To gain traction on this problem, it will likely be necessary to find treatments that address the key determinants of functional outcome. Evidence strongly suggests that cognitive deficits are among the key determinants of functional outcome for persons with schizophrenia. This finding underscores the basis for the current application. The current project's primary aim is to compare two training interventions based on cognitive rehabilitation to examine their potential benefits in promoting work outcome for persons with schizophrenia. The training interventions are: (a) errorless learning (a compensatory approach), and (b) a computerized cognitive remediation program (a cognition-enhancing approach). These two interventions were selected for comparison because they are representative of the field's latest advances and adaptations in cognitive rehabilitation training. The efficacy of these interventions will be examined within the context of an Individual Placement and Support model of supported employment, the leading evidence-based approach to supported employment for persons with SMI. The study is translational in that it extends laboratory-based efforts to a community mental health program. The study will recruit 144 study participants with schizophrenia or schizoaffective disorder who are interested in competitive employment. Study participants will be randomly assigned to one of three training groups: (a) errorless learning plus supported employment, (b) computer-based cognition-enhancing training plus supported employment, or (c) supported employment alone. After being placed at a competitive job in the community, study participants will be administered baseline assessments of cognition, clinical symptoms, work performance, and personal well-being and then followed for 12 months. Follow-up assessments will be conducted at 2-, 3-, 6-, 9-, and 12-months after initial job placement to examine short-term and longer-term training effects. The primary analyses will compare the effects of errorless learning and computer-based cognitive training against supported employment alone. Outcome measures will include measures of work performance, personal well-being, job tenure, and work outcome (e.g., wages). Secondary analyses will compare the effects of the two cognitive rehabilitation training interventions against one another, examine group differences on cognition, and examine the contribution of other potential key determinants (e.g., medication adherence, alcohol/substance use, motivation, life events) on work functioning.
The knowledge gained from the study will inform the field about the strengths and weaknesses associated with the latest cognitive rehabilitation interventions aimed at promoting work functioning for persons with schizophrenia. Regardless of the study findings, the results will provide direction for future efforts. Training materials may need to be modified, obstacles within the workplace may need to be addressed, or cognitive training programs altered to better suit the needs of this clinical population.
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