Randomized Trial of Social Rehabilitation and Integrated Health Care for Older People with Severe Mental Illness.

Many individuals with severe mental illnesses (SMI) such as schizophrenia and treatment-refractory mood disorders have prominent impairments in psychosocial functioning as they age (Bartels, Mueser, & Miles, 1997; Meeks & Murrell, 1997). Poor functioning in social relationships and independent living skills, combined with growing medical comorbidity (Druss, Bradford, Rosenheck, Radford, & Krumholz, 2000) and the loss of natural supports, makes this population highly vulnerable to long-term institutionalization in nursing homes and state hospitals (Meeks et al., 1990; Semke, Fisher, Goldman, & Hirad, 1996). Most older people with SMI live in the community (Meeks et al., 1990) and want to remain there (Bartels, 2003). In addition to the loss of independence and social dislocation inherent to institutionalization, the high cost of institutional care is concerning given the rapidly growing numbers of older people with SMI (Jeste et al., 1999). There is clearly a need to improve psychosocial functioning and to better prevent or manage chronic medical conditions of older people with SMI to improve long-term outcomes and minimize institutionalization (Atkinson & Coia, 1995; Blackmon, 1990). Substantial advances have been made in psychiatric rehabilitation for person with SMI (Corrigan, Mueser, Bond, Drake, & Solomon, 2008). However, the age-specific rehabilitative needs of older adults have been largely neglected. Patterson and colleagues (2003) developed the group-based, 24-week Functional Adaptation Skills Training (FAST) program designed to teach independent living, communication, and illness management skills. A small randomized controlled trial of FAST found that participants showed greater improvements in living skills on the UCSD Performance-Based Skills Assessment (UPSA) (Patterson, Moscona, McKibbin, Hughs, & Jeste, 2001) and in negative symptoms than a usual care group (Patterson et al., 2003). An adaptation of FAST for Spanish speaking older adults, PEDAL, was evaluated in a quasi-experimental study in which two mental health centers randomized to provide the program were compared to a center randomized to provide a support group (Patterson et al., 2005). PEDAL produced greater improvements on the UPSA at post-treatment, but group differences were no longer significant at 6- and 12-month follow-ups. Granholm, McQuaid, McClure, Pedrelli, and Jeste (2002) developed a 12-week program for middle-aged and older people with schizophrenia combining social skills training with cognitive restructuring. A small randomized controlled trial (N = 15) found that program participants showed greater improvements in overall symptoms and depression than the usual care group, but paradoxically worse negative symptoms. A larger scale controlled trial (N = 76) comparing the program with usual care found that program participants improved more in insight and in leisure and transportation skills at 6 months follow-up, but did not differ in overall living skills, symptoms, or hospitalizations (Granholm et al., 2005). These results are encouraging because they showed that older people with SMI can be engaged and retained in skills training, and that some improvements in symptoms or skills may result. However, several limitations should be noted. None of the studies evaluated social functioning (e.g., interpersonal relationships), an important focus of social skills training programs and a stated priority for many older individuals (Auslander & Jeste, 2002). Second, the studies lacked validated strategies for fostering the generalization of targeted skills to daily living, such as in vivo practice (Glynn et al., 2002) and the use of indigenous supporters (Tauber, Wallace, & Lecomte, 2000). A final limitation is the lack of attention to health concerns, despite the fact that poorly managed comorbid medical illness is a major contributor to institutionalization in aging people with SMI (Burns & Taube, 1990; Meeks et al., 1990). To address the rehabilitation needs of older people with SMI, we developed and pilot tested a combined skills training and health management intervention (Bartels et al., 2004; Pratt, Bartels, Mueser, & Forester, 2008). This program was designed to improve functioning and reduce institutionalization by teaching social, community living, and health maintenance skills. Based on promising results of this pilot program, the Helping Older People Experience Success (HOPES) program was developed. The HOPES program consists of a one-year intensive skills training phase, followed by a one-year maintenance phase. In addition to the core skills training component, the program also provides health care management by a nurse aimed at ensuring that participants receive preventive health care and management of chronic medical conditions. This report focuses on the two-year psychosocial outcomes of a randomized controlled trial comparing HOPES with treatment as usual (TAU). Because HOPES is aimed at teaching specific skills critical for effective psychosocial functioning, we used separate measures of each construct. Social skills were evaluated during performance-based role play tests. Psychosocial functioning was assessed based on participant interviews and clinician/informant ratings. We hypothesized that older adults receiving HOPES would show greater improvement in both social skills and psychosocial functioning. Within the domain of psychosocial functioning, we also speculated that HOPES would produce greater improvements in leisure and recreation skills because the program specifically targets this domain. We hypothesized that we would obtain stronger effects on performance measures of skill, which are more proximal to the intervention, than measures of psychosocial functioning, which are more distal. We also hypothesized that HOPES would produce greater improvements in self-efficacy, because the program was designed to teach skills to empower people to take greater care of themselves, and greater reductions in negative symptoms, because they are strongly related to psychosocial functioning (Pogue-Geile & Harrow, 1985).