ASPIRE Cognitive Enhancement Study
Condition: Homelessness; Mental Health Conditions
Study type: Interventional

Summary: 
      Cognitive impairments are present in up to 80% of homeless individuals, and may contribute to
      homelessness in Operation Enduring Freedom / Operation Iraqi Freedom / Operation New Dawn
      (OEF/OIF/OND) Veterans. The investigators propose to investigate these issues in homeless,
      treatment-seeking returning Veterans, who arguably face multiple potential barriers to
      recovery and reintegration, and with whom there is the greatest opportunity to prevent
      long-term homelessness. The investigators plan to conduct a 15-week randomized controlled
      trial of an evidence-based, 10-week Compensatory Cognitive Training (CCT) intervention vs. an
      education control condition to examine the effects of cognitive rehabilitation in this
      Veteran population. The investigators expect CCT-associated improvements in cognition and
      functional skills and generalization to reduced levels of disability, along with improved
      community reintegration outcomes. By attending to and treating cognitive impairments, the
      investigators can potentially prevent future homelessness and its negative health
      consequences, resulting in both healthcare cost savings and improved quality of life for
      Veterans.
    

Detailed description: 
      This study integrates cognitive rehabilitation in residential care for homeless Veterans. In
      a 15-week randomized controlled trial, the investigators will compare an evidence-based,
      10-week Compensatory Cognitive Training (CCT) intervention to an education control condition
      for homeless Veterans with cognitive impairment. CCT aims to improve real-world cognitive
      performance by teaching strategies to improve prospective memory (remembering to do things),
      attention, learning/memory, and executive functioning. Strategies to reduce stress and
      improve sleep are also included. CCT has been shown to improve cognition, functional
      capacity, neurobehavioral symptom severity, and quality of life in individuals with cognitive
      impairment associated with psychiatric illness and in Veterans with traumatic brain injury
      (TBI). During the trial, assessments will be administered at baseline, 5 weeks, 10 weeks, and
      15 weeks, and monthly follow-up phone calls will assess housing and employment/education
      status for one year following program discharge. The investigators expect CCT-associated
      improvements in cognition and functional skills (co-primary outcomes) and generalization to
      reduced levels of disability, along with improved community reintegration outcomes (better
      housing stability, participation in work or school, and healthcare appointment attendance).
      If effective, the CCT intervention could be exported to the 80+ residential VA programs
      serving homeless Veterans. The investigators thus propose the following aims:

      Aim 1. Investigate the efficacy of cognitive rehabilitation in homeless returning Veterans
      with mental health conditions and cognitive impairment by conducting a randomized controlled
      trial of Compensatory Cognitive Training (CCT) vs. education control for 10 weeks, with a
      5-week follow-up, followed by 1 year of monthly post-discharge follow-up phone calls to
      assess community reintegration outcomes.

      H1a: Positive CCT-associated effects on cognition, functional capacity (co-primary outcomes),
      and disability will emerge over the 15-week study.

      H1b: Positive CCT-associated effects on community reintegration outcomes (housing stability,
      participation in employment/education, healthcare appointment attendance) will be detected at
      the end of the 1-year follow-up.

      Aim 2. Investigate mechanisms of CCT effects. H2: Improved cognition and cognitive strategy
      use will mediate improvements in functional capacity, disability, and community
      reintegration.

      Exploratory Aim 3. Investigate moderators of CCT effects. Presence and severity of
      Posttraumatic Stress Disorder (PTSD), depression, history of substance abuse, and TBI, as
      well as duration of homelessness and baseline cognitive functioning, will be explored as
      potential moderators of CCT effects.
    

Intervention name(s): CCT; HCE
Intervention type(s): Behavioral; Behavioral
Intervention description(s): 10-week Compensatory Cognitive Training; 10-week Holistic Cognitive Education
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Homeless persons; Veterans; Mental disorders; Cognition; Rehabilitation