19.3 APPLYING COGNITIVE ADAPTATION TRAINING IN FINLAND: INTERIM RESULTS OF THE FINNISH CAT IMPLEMENTATION PROJECT

Abstract Background In Finland, approximately 50 000 people have a diagnosis of schizophrenia. In practice 6% of them reside permanently in mental hospitals. There is a national target to reduce the number of psychiatric hospital beds. However, as hospitals are closed there is a tendency to place schizophrenia patients in different types of sheltered housing instead of supporting them to live independently in the community. In the Danish OPUS-study 94 patients with first episode schizophrenia were followed and even those who had attended a vigorous rehabilitation program lived about two and a half months in sheltered housing in the fifth year after their diagnosis. Thus, with deinstitutionalization we are building up a poorly monitored system of sheltered housing for schizophrenia patients. This system may increase chronic need for support, is expensive and marginalizes a large section of people from the community. When service users are asked they usually prefer having their own homes. Cognitive adaptation training (CAT) is a home-based, manual-driven treatment that utilizes environmental supports and compensatory strategies to bypass cognitive deficits and improve target behaviors and functional outcomes in individuals with schizophrenia. Unlike traditional case management, CAT provides environmental supports and compensatory strategies tailored to meet the behavioral style and neurocognitive deficits of each individual patient. CAT has been shown to be effective in improving service users’ ability live independently. Methods The study started in 2014. After formal CAT training the program was implemented in the Hyvinkää Hospital and Helsinki University Central Hospital treatment catchment areas (approx. 1 350 000 inhabitants). For the study we selected patients that were in risk of moving to a more supported housing environment due to the presence of cognitive deficits that threatened their ability to live independently. The only exclusion criteria were heavy alcohol and drug abuse and known aggressive behavior. The outcome measurements include both qualitative and quantitative methods: transfer to a different type of housing, need for hospital treatment, psychiatric rating scales, observed measurements and open interviews, and are measured after 4 months after the start of the intervention, at the end of the 9 month intervention and after a 6 months follow-up period. Results We report here preliminary interim results for the patients who have completed the study so far. Altogether 48 patients were selected for the intervention, which was found to be well-received with 7 patients dropping out. The mean age was 38.9 year, with 39.3 % women and 60.4 % men. 27.6 % were living independently, 22.9 % with their parents, and 29.6 % living in some form of sheltered housing. Participants had severe to moderately-severe psychiatric symptoms and functional impairment (mean GAF 47.8, mean SOFAS 54.8). Apathetic was the most common behavioral subtype (70.7 %), with disinhibited (14.6 %) and mixed (14.6 %) subtypes following. Discussion Cognitive Adaptation Training can be used to help patients in a wide range of living situations and with severe psychiatric symptoms and functional impairment to maintain their ability to live independently.


APPLYING COGNITIVE ADAPTATION TRAINING IN FINLAND: INTERIM RESULTS OF THE FINNISH CAT IMPLEMENTATION PROJECT
Tuukka Mehtala* ,1 , Satu Viertio 2 , Eila Sailas 3 1 HUS; 2 National Institute for Health and Welfare; 3 Kellokoski Hospital Background: In Finland, approximately 50 000 people have a diagnosis of schizophrenia. In practice 6% of them reside permanently in mental hospitals. There is a national target to reduce the number of psychiatric hospital beds. However, as hospitals are closed there is a tendency to place schizophrenia patients in different types of sheltered housing instead of supporting them to live independently in the community. In the Danish OPUS-study 94 patients with first episode schizophrenia were followed and even those who had attended a vigorous rehabilitation program lived about two and a half months in sheltered housing in the fifth year after their diagnosis. Thus, with deinstitutionalization we are building up a poorly monitored system of sheltered housing for schizophrenia patients. This system may increase chronic need for support, is expensive and marginalizes a large section of people from the community. When service users are asked they usually prefer having their own homes. Cognitive adaptation training (CAT) is a home-based, manual-driven treatment that utilizes environmental supports and compensatory strategies to bypass cognitive deficits and improve target behaviors and functional outcomes in individuals with schizophrenia. Unlike traditional case management, CAT provides environmental supports and compensatory strategies tailored to meet the behavioral style and neurocognitive deficits of each individual patient. CAT has been shown to be effective in improving service users' ability live independently. Methods: The study started in 2014. After formal CAT training the program was implemented in the Hyvinkää Hospital and Helsinki University Central Hospital treatment catchment areas (approx. 1 350 000 inhabitants). For the study we selected patients that were in risk of moving to a more supported housing environment due to the presence of cognitive deficits that threatened their ability to live independently. The only exclusion criteria were heavy alcohol and drug abuse and known aggressive behavior. The outcome measurements include both qualitative and quantitative methods: transfer to a different type of housing, need for hospital treatment, psychiatric rating scales, observed measurements and open interviews, and are measured after 4 months after the start of the intervention, at the end of the 9 month intervention and after a 6 months follow-up period. Results: We report here preliminary interim results for the patients who have completed the study so far. Altogether 48 patients were selected for the intervention, which was found to be well-received with 7 patients dropping out. The mean age was 38.9 year, with 39.3 % women and 60.4 % men. 27.6 % were living independently, 22.9 % with their parents, and 29.6 % living in some form of sheltered housing. Participants had severe to moderately-severe psychiatric symptoms and functional impairment (mean GAF 47.8, mean SOFAS 54.8). Apathetic was the most common behavioral subtype (70.7 %), with disinhibited (14.6 %) and mixed (14.6 %) subtypes following. Discussion: Cognitive Adaptation Training can be used to help patients in a wide range of living situations and with severe psychiatric symptoms and functional impairment to maintain their ability to live independently.

CAT IN FIRST-EPISODE PSYCHOSIS: FEASIBILITY, ACCEPTABILITY AND POTENTIAL TO ENHANCE VOCATIONAL RECOVERY
Kelly Allott* ,1

Orygen, The National Centre of Excellence in Youth Mental Health
Background: Cognitive and functioning impairments are present early in the course of psychotic disorder and remain one of the greatest treatment challenges in this population. While Cognitive Adaptation Training (CAT) is found to improve a range of outcomes in chronic schizophrenia, it has received limited investigation in first-episode psychosis (FEP). CAT may be particularly useful for addressing vocational recovery in FEP because the cognitive impairments experienced by individuals with FEP predict poorer vocational outcomes and impede the effectiveness of vocational interventions such as supported employment. The aim of this presentation is to present the findings of a pilot study investigating the feasibility and acceptability of CAT in young people with FEP and to describe the clinical considerations and adaptations required when delivering CAT with this population. Preliminary findings on the potential value of CAT in improving vocational outcomes in FEP will also be presented.

Methods:
This was a single-arm feasibility study of CAT conducted at the Early Psychosis Prevention and Intervention Centre (EPPIC), Melbourne, Australia. Five FEP participants received 9 months of manually-guided CAT. A range of feasibility and acceptability measures were recorded, including participant and case manager satisfaction ratings. Participants' goals, functional needs and clinical observations and adaptations were also recorded. Formal measures of functioning, quality of life and motivation were independently administered pre-and post-intervention. Results: All participants completed the CAT intervention and session attendance rates were very high (95.3%). Participants and their case managers indicated strong satisfaction with CAT as indicated by overall positive mean ratings on the satisfaction items. CAT did not negatively affect existing case management, with case managers reporting that it enhanced their treatment. Vocational recovery (education, employment) was found to be a primary functional goal of most participants. Accordingly, the CAT intervention had a strong focus on vocational functioning, including functional domains that are requisite for successful work or educational outcomes, including organisation and planning, transportation and activities of daily living. Being mindful of factors that may be common in young FEP patients included cognitive heterogeneity, family involvement, flexibility in compensatory and environmental supports used, and the experience of stigma. There were mean improvements from baseline to post-intervention on most formal outcome measures, with the largest effects in global functioning, planning and organisation, and quality of life. Discussion: This study provides encouraging preliminary evidence that CAT is a highly feasible and acceptable intervention in FEP, which may be easily integrated within existing early intervention services. Vocational recovery is important to young people with FEP. CAT is an intervention that appears well suited to addressing this need. The effectiveness of CAT in improving functional outcomes, particularly vocational recovery in FEP warrants further investigation in a larger trial.

THE APPLICATION OF STEM CELL MODELS TO VALIDATE RARE AND COMMON VARIANTS CONTRIBUTING TO SCHIZOPHRENIA Kristen Brennand Icahn School of Medicine at Mount Sinai
Overall Abstract: As expanding genetic studies increasingly demonstrate that both rare variants of large impact and common variants of small effect contribute to schizophrenia, it becomes increasingly critical