It is well established that poor adherence to antipsychotic medication can lead to relapse and re-hospitalization for schizophrenia patients. Prominent among the many reasons for non-adherence to pharmacotherapy are cognitive deficits, which contribute to forgetting to take medication and the failure to establish routines that would promote adherence. In a series of studies, we showed that Cognitive Adaptation Training (CAT) --- a manual-driven set of environmental supports (signs, checklists, electronic devices) designed to bypass specific neurocognitive deficits --- significantly improved symptomatology, adaptive functioning and rates of relapse in schizophrenia patients compared to control conditions. One interpretation of these results is that the environmental supports established specifically to increase adherence to medications were responsible for the better outcomes observed in CAT. We plan to examine this issue in a sample of 90 schizophrenia patients on atypical antipsychotic medications. After obtaining blood levels during hospital stay to determine intra-individual variability in plasma concentration of antipsychotic medication during optimal adherence, patients will be followed prospectively from the time of discharge for three months. This will allow us to examine predictors of poor adherence to atypical antipsychotics in the sample. Next, patients will be randomly assigned for 9 months to one of three treatment groups: (1) Full-CAT, (a comprehensive use of environmental supports to improve multiple areas of adaptive functioning), (2) Pharm-CAT (supports for medication adherence only), (3) Treatment as usual. All patients will be followed for 6 months after CAT treatments have been discontinued. Primary outcome variables will include medication compliance (blood levels), and measures of symptomatology, and adaptive functioning obtained at study entrance and each 3 months. Analyses of covariance, with pretreatment scores used as covariates, will be utilized to examine group differences on the outcome variables at the end of treatment and follow-up. We hypothesize that both Pharm-CAT and Full-CAT will improve adherence, symptomatology and rates of relapse but that only the comprehensive Full-CAT program will improve adaptive functioning. Moreover, we hypothesize that compliance and functioning will return to baseline levels six months after discontinuation of treatment.
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