SCIT Versus TAR for Outpatients With Schizophrenia
Condition: Schizophrenia
MeSH terms: Schizophrenia
Study type: Interventional

Summary: 
      The present work consists of a randomized clinical trial comparing the effectiveness of two
      interventions based on social cognition training in outpatients with schizophrenia. The
      investigators sought to compare the effect of a "targeted" (TAR) and a "broad-based" (SCIT)
      intervention on schizophrenia patients' performance in facial affect recognition, theory of
      mind and attributional style. Secondarily, the investigators compare the effect on
      symptomatology, general cognition and functioning. The main hypothesis was that the patient
      group receiving TAR would exhibit a greater improvement in emotion recognition performance at
      the post-intervention assessment in comparison to patients receiving the SCIT, and,
      conversely, patients receiving SCIT would show more effect in ToM and attributional style. To
      assess the durability of these effects, performance in measures of social cognition, basic
      cognitive functioning, symptomatology and functional capacity were assessed before (T0),
      after treatment (T1) and 3 months later (T2).
    

Detailed description: 
      In recent years, there has been an interest in the development of intervention programs
      focused on the social cognition for people with schizophrenia (Andres et al., 2001; P Penn et
      al. 2005). At least, five reviews and one meta-analysis have been conducted to date, which
      demonstrate promising results of the effectiveness of such interventions on social cognitive
      deficits and functional outcomes (Tan et al; 2016; Choi et al., 2009; Horan et al., 2008;
      Kurtz and Richardson, 2012; Statucka and Walder, 2013; Wolwer et al., 2010). Some approaches
      are focused on one specific domain of social cognition ("targeted" interventions, such as the
      Training in Affect Recognition (TAR, Wolwer et al., 2005), and others incorporate multiple
      domains to create more complex, eclectic programs ("broad-based" interventions, such as the
      Social Cognition and Interaction Training (SCIT; Penn et al. 2007; Kurtz & Richardson, 2012).

      TAR (Frommann et al., 2003) is one of the social cognition interventions with greater
      empirical support (Statucka & Walder, 2016) and has been shown to effectively attenuate
      facial affect recognition deficits in patients with schizophrenia (Wölwer et al. 2005; Wölwer
      and Frommann 2011; Sachs et al. 2012; Luckhaus et al. 2013). TAR teaches compensation
      strategies using errorless learning principles, positive reinforcement, feature abstraction,
      self-instruction and, most importantly, verbalization of characteristic features of facial
      affect. In a randomized controlled trial, the TAR group achieved significant improvements in
      facial affect recognition -in particular in recognizing sad faces- and in the quality of life
      domain social relationship. Furthermore, the TAR training contributed to enhancing some
      aspects of cognitive functioning and negative symptoms (Sachs et al, 2012). In the other
      hand, SCIT is a 24-session manual-based group treatment, including elements of cognitive
      behavioral therapy and social skills training. It is designed for those with schizophrenia
      spectrum disorders to improve social functioning by enhancing social cognition. Across
      different studies and research groups, SCIT has been also shown to improve in emotion
      perception, theory of mind (ToM), and social functioning (Bartholomeusz et al., 2013; Combs
      et al., 2007; Hasson-Ohayon, 2014; Parker et al. 2013; Penn et al., 2007; Roberts & Penn,
      2009; Roberts et al. 2010; Roberts et al., 2014, 2016; Wang et al., 2013).

      The efficacy of both interventions has been demonstrated in randomized controlled trials
      compared to "treatment as usual", occupational therapy or cognitive remediation (Kurtz et al.
      2016) but to date no study has compared the efficacy of two different social cognitive
      interventions (a direct comparison design). A more precise knowledge about the effect of each
      intervention on the 4 main domains of social cognition (affect recognition, theory of mind,
      attributional style and social perception) is needed, and this would enable to identify
      potential candidates for each program.

      The present work consists of a randomized clinical trial comparing the effectiveness of two
      interventions based on social cognition training in outpatients with schizophrenia. The
      investigators sought to compare the effect of a "targeted" (TAR) and a "broad-based" (SCIT)
      intervention on schizophrenia patients' performance in facial affect recognition, theory of
      mind and attributional style. Secondarily, the investigators compare the effect on
      symptomatology, general cognition and functioning. The main hypothesis was that the patient
      group receiving TAR would exhibit a greater improvement in emotion recognition performance at
      the post-intervention assessment in comparison to patients receiving the SCIT, and,
      conversely, patients receiving SCIT would show more effect in ToM and attributional style. To
      assess the durability of these effects, performance in measures of social cognition, basic
      cognitive functioning, symptomatology and functional capacity were assessed before (T0),
      after treatment (T1) and 3 months later (T2).

      2. Methods

      2.1. Participants Outpatients who met DSM-IV criteria for schizophrenia and schizoaffective
      disorder (SCID-P; First et al. 1994) with stable symptoms in the range from 18 to 65 years
      were included into the study. Patients were recruited from 4 Mental Healt Centers in Madrid,
      Barcelona, Zaragoza and Teruel (Spain). All were clinically stable, without any psychiatric
      hospitalizations in the last 3 months, with the same antipsychotic medication during the
      previous 6 weeks, and no planned change in the drug regime for the next 3 months. Exclusion
      criteria were: 1. Disorders other than schizophrenia or schizoaffective disorder, according
      to DSM-IV diagnosis criteria; 2. Additional axis-I or axis-II diagnosis; 3. Dependence to
      alcohol or other drugs (except nicotine); 4. Serious somatic disorders or organic brain
      damage; 5. Mental retardation or difficulty speaking or understanding the Spanish language.

      The study was approved by the loval ethics committee and all participants gave their informed
      consent. Overall 100 participants were randomized either to TAR group (n = 49) or to the SCIT
      group (n = 51) (Consort diagram, Graphic 1).

      2.1.1. Treatment

      TAR is a 12-session training on facial affect recognition over a period of 6 weeks. Treatment
      includes one therapist (psychiatrist or clinical psychologist) and 2 patients. It involves
      neuropsychological strategies, such as restitution and compensation, as well as principles of
      errorless learning, direct positive reinforcement, verbalization and self-instruction
      (Frommann et al., 2003; Wölwer et al., 2005). The program is divided into three blocks,
      whereas each block consists of 4 sessions: during the first block patients learn to identify
      and discriminate the prototypical facial signs of the six basic emotions (happiness, sadness,
      fear, disgust, anger and surprise). The next block aims at a more holistic processing mode
      with fast decisions, relying on first impression, nonverbal processing and recognition of
      facial expressions with small intensities. The third block deals with the role of facial
      emotions in social, behavioral and situational context. Baseline assessments
      (T0=pre-treatment) were performed after enrolment to the study and post treatment assessments
      (T1=post-treatment) after the end of the training period (Sachs et al. 2012).

      SCIT is a manual-based group intervention that is delivered in 20-24weekly, hour-long
      sessions. Groups include two clinicians and six to ten patients. SCIT uses a combination of
      psychoeducation, drill-and-repeat skill practice, strategy games, heuristic rehearsal, and
      homework assignments to remediate deficits and decrease biases in social cognition. Each SCIT
      group participant was encouraged to identify a 'practice partner', a family member or
      acquaintance who was willing to practice SCIT skills with the participant weekly in lieu of,
      or in addition to, traditional homework. SCIT clinicians attempted to reach practice partners
      by phone each week to check -in and provide guidance in their efforts to support SCIT
      participants' learning (Roberts et al. 2014).
    

Intervention name(s): SCIT; TAR
Intervention type(s): Behavioral; Behavioral
Intervention description(s): SCIT is a 18 weekly sessions lasting 45-60 minutes per session. The group will include 8-12 patients, with 2 therapists. The content of the sessions is based on the Spanish translation of the original SCIT (Social Cognition and Interaction Training) instruction manual (Combs, Adams, et al., 2007); (G. Lahera et al., 2013). The manual of the program developed for the improvement of emotional perception skills, attributional style and theory of mind in people with schizophrenia.; TAR is a 12-session training on facial affect recognition over a period of 6 weeks. Treatment includes one therapist (psychiatrist or clinical psychologist) and 2 patients. It involves neuropsychological strategies, such as restitution and compensation, as well as principles of errorless learning, direct positive reinforcement, verbalization and self-instruction (Frommann et al., 2003; Wölwer et al., 2005).
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: A randomized three group pre-post design will be used to investigate effects of the Training of Affect Recognition (TAR), compared to the Social Cognition and Interaction Training (SCIT). Performance in social cognition measures, basic cognitive functioning symptomatology and functional capacity will be assessed before (T0), after (T1) treatment and (T2) 3 months later.
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: social cognition; psychotherapy; rehabilitation; theory of mind