Improving vocational outcomes in first-episode psychosis by addressing cognitive impairments using Cognitive Adaptation Training

Abstract

BACKGROUND: Cognitive Adaptation Training (CAT) uses compensatory strategies and environmental supports to support cognitive impairments and improve functioning. CAT may be useful for addressing vocational recovery in first-episode psychosis (FEP) because cognitive impairments are common and vocational recovery is a key goal of young people with FEP.

OBJECTIVE: To describe clinical observations and practice experience when delivering CAT with FEP clients and explore potential benefits via objective outcome measures for improving vocational outcomes.

METHODS: In this pilot study, five FEP participants received 9 months of CAT. Participant goals and functional needs and clinical observations were recorded. Formal measures of functioning, quality of life and motivation were independently administered pre- and post-intervention.

RESULTS: Vocational recovery (education, employment) was found to be a primary functional goal of FEP participants. Accordingly, CAT had a strong focus on vocational functioning, including functional domains required for successful work or educational outcomes, such as organization and planning, transportation and activities of daily living. Factors of clinical importance when delivering CAT with the FEP participants included cognitive heterogeneity, family involvement, flexibility in compensatory and environmental supports used, and experience of stigma. Improvements from baseline to post-intervention were observed on most measures, with the largest improvements seen in global functioning (including vocation), planning and organization, and quality of life.

CONCLUSIONS: CAT is an intervention that appears well suited to addressing vocational functioning in FEP, but larger controlled trials are needed.

Keywords

Cognition vocational recovery supported employment compensatory strategies environmental supports schizophrenia

1 Introduction

Vocational recovery is a fundamental treatment concern for individuals who have experienced psychosis [1 –3]. Large and widespread cognitive impairments (e.g., in executive functioning, verbal and visual learning and memory, attention, working memory, processing speed, language and visual functions) are shown to develop early in the course of psychotic illness and are consequently frequently observed in young people with first-episode psychosis (FEP) [4]. Cognitive impairments are shown to be significantly related to functional outcomes in psychosis, including vocational outcomes [5, 6].

There has been little research into the potential utility of cognitive compensatory approaches for vocational rehabilitation during the early phase of illness [7, 8]. Cognitive Adaptation Training (CAT) is a standardized manual-based psychosocial intervention that was developed to address the cognitive and functional needs of people with chronic schizophrenia [9]. The CAT model is underpinned by an empirically-informed framework in which cognition, particularly executive functioning (i.e., planning, organization, inhibitory control), is considered integral to optimal adaptive functioning. The application of CAT is based on neuropsychological, behavioural, and occupational therapy principles and involves a compensatory approach to rehabilitation, where environmental adaptations and supports (e.g., signs, alarms, calendars, reduced distractions) and compensatory strategies (e.g., routines, breaks, step-by-step directions) are implemented to support or ‘work around’ cognitive impairments and directly address functional goals.

In practice, a comprehensive assessment is conducted, which involves assessment of 1) cognition (e.g., executive functioning, memory, processing speed, attention) using standard neuropsychological tests to identify strengths and weaknesses, and 2) an assessment of the home environment, daily activities and goals to identify CAT targets using an Environmental and Functional Assessment (EFA) [9]. The EFA covers orientation, daily/weekly routine, safety and hygiene, ownership of items needed for daily tasks (e.g., clock, personal hygiene items), activities of daily living (ADL), medication management, financial management, social and recreational activities, and vocational functioning. The participant, caregivers (if appropriate), and treating team are given feedback about the assessment findings, including psychoeducation about cognition, psychosis and functioning. A bespoke CAT program is developed according to the person’s cognitive deficits and strengths and how these relate to the functional needs identified. CAT is delivered on a one-to-one basis in the community (participant’s home, local community, school, and workplace) for approximately one hour per week. CAT is adapted to the individual and is not dependent on the number or severity of cognitive deficits. Participant needs and CAT strategies are reviewed and refined weekly with the participant. CAT encourages habit formation and the automaticity of constructive daily behaviours through repeated practice. For example, to support organization and memory difficulties compensatory strategies might include routine use of signs, reminders and alarms to prompt the completion of desired and goal-directed tasks and the use of calendars and checklists to assist with organization, planning and completing daily or weekly activities. CAT has been found to be effective for improving several outcomes for people with chronic schizophrenia, including ADL, medication compliance, motivation, quality of life, symptoms and hospitalisation rates [10 –13]. Vocational functioning has also been shown to improve following CAT, including increased time spent in work-related activities [14] and global measures of occupational functioning [15, 16]. Few studies have investigated the use of CAT in FEP [8, 12].

There are several reasons why a cognitive compensatory and adaptive approach such as CAT may be a valuable component of interventions for improving functioning in FEP. First, CAT focuses on the individual’s functional goals (e.g., work and education), which are rated by young FEP patients as more important than alleviation of their psychiatric symptoms [1 , 18]. Second, CAT involves the implementation of strategies in the individual’s home and community environment, which may be highly engaging and less stigmatising for young people, as there is no need to attend a specific clinic and personal goals addressed in vivo. Third, a majority of young people with FEP live with their family of origin, so CAT has the potential to decrease family burden [19]. Fourth, CAT is an individualized treatment program that is delivered flexibly with participants which is crucial for engaging and treating young FEP patients, whose insight, goals and adjustment to illness are in flux during this early illness stage [3, 20]. Finally, in a recent trial of Individual Placement and Support (IPS) [21] versus usual treatment in FEP, cognitive impairment (specifically in visual organization and memory) was predictive of lower employment duration over 6 months regardless of vocational treatment group [6]. CAT may be useful for enhancing vocational outcomes by supporting the behaviours required to gain and maintain employment and education, which are often impeded by cognitive impairment [6 , 23]. For example, general behaviours such as organizational skills, punctuality, self-care, medication management, as well as specific occupationally-related skills, such as multi-tasking, following procedures, and remembering tasks to be completed.

We recently piloted CAT with five young FEP participants to determine whether it was an acceptable, feasible and potentially useful intervention for this population. CAT was found to be feasible and acceptable as indicated by high attendance and completion rates and generally positive feedback was received from participants and their case managers [8]. Comprehensive details of the feasibility and acceptability findings are reported elsewhere [see 8]. Interestingly, we found in the pilot study that a large focus of the CAT intervention was in relation to education and vocational goals and the requisite daily activities required for being successful in school or work. Thus, the purpose of this paper is to report on the goals and functional needs of the FEP participants in the pilot study [8], how these were addressed by CAT, and the associated functional outcomes, with a particular focus of vocationalrecovery.

2 Methods

2.1 Setting and participants

The study was conducted at the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne, Australia. EPPIC is a public mental health service that provides up to 2 years of treatment for individuals aged 15–25 years who have experienced a first episode of psychosis. Five young FEP clients participated in the study. To be included participants met one or more of the following criteria: difficulty performing ADL; difficulty with independent living; difficulty maintaining employment/education; desire for transition to a more independent living environment; desire to work or study; desire for increased medication/treatment compliance; or desire for increased community/leisure/social participation [9]. Further inclusion criteria to be able to deliver CAT were that the individual was living in a stable environment; the environmental or clinical risk was assessed as low; and they had more than 9 months of treatment remaining with the clinical service to ensure ongoing treatment during the study. Exclusion criteria included: a diagnosed intellectual disability, neurological disorder, florid psychosis, or insufficient English. Participants provided written informed consent after receiving a full explanation of the study (all recruited participants were aged 18 years and over). Ethics approval was granted from the local Human Research Ethics Committee.

Following the assessment participants received up to 9 months of manual-based CAT [9], which was individually-tailored based on the assessment and provided by a clinical neuropsychologist. While receiving CAT they continued to receive standard EPPIC treatment comprising fortnightly case management and medical review.

2.2 Measures

Participant goals and functional needs and qualitative observations were recorded by the CAT therapist, as well as any adaptations to CAT required for the FEP participants. Formal outcome measures were administered by an independent research assistant at baseline and again at 9 months (post-CAT). Measures included: the Social and Occupational Functional Assessment Scale (SOFAS) as an index of real-world functioning [24]; the UCSD Performance-Based Skills Assessment (UPSA-2) [25], as a measure of functional capacity in the domains of financial skills, communication skills, planning and organization, transportation, and household skills; and the World Health Organization Quality of Life (WHOQOL-BREF) [26] as a measure of subjective quality of life in the domains of physical health, psychological health, social relationships, and environment. The Behavioural Inhibition and Behavioural Activation Scales: The BIS/BAS [27] is a self-report measure of motivation that examines two systems of motivation believed to underlie behaviour: behavioural inhibition and behavioural activation(drive, fun seeking, and reward responsiveness). The BIS/BAS was also included because previous research investigating CAT in chronic schizophrenia found that CAT led to increased motivation in participants [13]. We wished to examine whether CAT might also improve motivation in FEP participants, given that motivation is likely to influence vocational recovery.

2.3 Statistical analysis

Given the small sample only descriptive summary statistics at baseline and post-CAT were calculated (using IBM SPSS Statistics 21).

3 Results

3.1 Sample characteristics

Three females and two males with FEP with a mean age of 21.4 (SD = 2.2) and 11.8 (SD = 2.2) years of education received CAT. Four participants lived at home with their family of origin and one lived in transitional supported accommodation. Three participants were unemployed; one was undertaking a university degree; and one was engaged in a university degree and part-time employment.

The diagnoses of the participants were schizophrenia (n = 3), schizoaffective disorder (n = 1) and bipolar disorder with psychotic features (n = 1). Four of the five participants were prescribed second-generation antipsychotic medication and reported taking it compliantly. One participant was not prescribed medication. At study entry the mean length of psychosis was 1.8 (SD = 1.5) years and the mean length of treatment was 9.0 (SD = 3.0) months.

3.2 Individual goals and functional needs of FEP participants receiving CAT

Table 1 lists the ten functional needs that were identified and addressed with the CAT intervention for the five participants. Education was the most commonly identified domain of need, with all five participants citing education as a primary goal for CAT. For example, a desire to return to and complete secondary or tertiary education, which had been significantly interrupted and completing the curriculum had become more difficult due to their psychotic illness and cognitive impairment. The other three most frequently targeted domains were general organization and planning (which was impacting on both home- and community-based functioning), employment, and transportation. A large focus of CAT, therefore, was in supporting planning and organization using visual aids such as calendars, diaries and checklists to support behaviours required for work and education. In relation to work, participants required assistance both in obtaining employment as well as strategies and interventions for maximizing job performance and maintaining employment. An interesting anecdotal observation was that four of the five participants had previously received IPS from the employment consultant at EPPIC, while one continued to receive IPS, but a need for additional support in gaining and maintaining education and/or employment was indicated by the treating team, including the employment consultant. Regarding transportation goals, one participant required assistance in strategies for using public transport (despite being premorbidly adept), which was identified as an essential pre-requisite for him in being able to obtain and maintain work. Four of the five participants possessed a learner’s driving permit and three of these participants specifically requested assistance in gaining their full driver’s license, which appears to be a developmental milestone that is especially relevant in young FEP patients and presents as a barrier to gaining their independence.

Table 1
Functional needs identified and addressed by CAT in five FEP participants

Functional Domain Participant

Education/school 1, 2, 3, 4, 5

Organization and planning 1, 2, 4, 5

Work 1, 2, 4

Transportation 1, 4, 5

Hygiene/personal care 1, 2

Leisure/social skills 1, 5

Household chores 1, 5

Orientation 4, 5

Budgeting/financial management 2

Cooking skills 3

Functional Domain	Participant
Education/school	1, 2, 3, 4, 5
Organization and planning		1, 2, 4, 5
Work	1, 2, 4
Transportation	1, 4, 5
Hygiene/personal care	1, 2
Leisure/social skills	1, 5
Household chores	1, 5
Orientation	4, 5
Budgeting/financial management	2
Cooking skills	3

3.3 Clinical observations and adaptations of CAT for FEP

Detailed case notes of the CAT assessment and intervention and general clinical observations were undertaken to determine where adaptations to CAT might be needed for FEP participants, relative to chronic schizophrenia samples. The following observations may be useful for clinicians embarking on using compensatory strategies and environmental supports to improve vocational functioning in this population.

The first observation was the cognitive heterogeneity within the sample. The estimated premorbid IQ of participants ranged from 65 to 107 (*Two participants scored below 70 on the premorbid IQ assessment, which was based on a word reading task. One participant was suspected of having possible learning/reading difficulties and for the other, English was the second language. In both cases, a diagnosis of intellectual disability was not suspected). Thus, for some participants, considerable longstanding premorbid cognitive difficulties were evident, whereas for others cognitive deficits had emerged closer to or during the development of their FEP against a background of preserved intellectual function. Further, we observed that the FEP participant with bipolar disorder with psychotic features showed greater improvements in cognition with improvements in psychiatric symptoms, whereas those with non-affective psychosis tended to experience residual deficits despite symptomatic remission. Accordingly, the participant with bipolar disorder required half the ‘dose’ (total number of sessions and length of intervention) of CAT compared to the other participants [see 8 for further details], while the specific CAT strategies implemented did not differ based on diagnosis.

Regardless, the impact of experiencing FEP was associated with a significant decline from premorbid functioning levels, and thus, a large component of CAT was assisting participants to return to previous levels of functioning. This was noted in several domains, but especially in self-care/hygiene, use of public transport, social engagement, and academic achievement. An emphasis on providing individually-tailored information on the relationships between cognition, behaviour and functioning in psychosis was provided to the participants, families, EPPIC clinicians and external support workers in order to maximize successful outcomes and was anecdotally very well-received.

An initial focus on simple interventions that were likely to lead to early success and were relevant to the stated goals of the young FEP participants was particularly important for engagement, motivation and self-efficacy. Regarding environmental supports (i.e., external compensatory aids), the most common and regularly used supports were calendars and diaries (3/5 participants). Salient signs/labels or checklists were also placed in the home to target/prompt specific behaviours for three of the five participants. Portable environmental supports were developed in some instances, such as a step-by-step pocket guide to reading a bus/train timetable or a prompt card for practicing common job interview questions or answering the phone at work. It was anticipated that because the participants were adolescents and young adults, there would be a high use of electronic compensatory aids (such as smart phone apps or the Internet) for orientation, prompting, check-lists, references, etc. However, only one of the five participants owned a smart phone (not web-enabled), and she preferred to use a diary, calendar and written to-do lists to aid organization and memory. One participant used her mobile phone for reminders to complete specific ADL, but also used a paper-based diary. Examples of specific CAT interventions used in relation to work are presented in Table 2.

Table 2
Example CAT interventions for addressing cognitive impairments affecting work

Cognitive and work difficulties identified Example CAT strategies used

Concerned about work speed (fast-food store) - Requested shifts at ‘quieter’ periods, rather than at lunchtime ‘rush’

Punctuality/being late - Training in use of alarm clock – setting early enough to catch bus

- Leave curtain open at night so patient wakes with natural light

Grooming – pants too low, revealing buttocks (was given warning at work) - Purchased new ‘higher’ waist pants

- Established routine of ‘checking self’ in mirror before leaving home

Remembering tasks given (receptionist) - Carry pen and notepad and write things down to remember

- Training in use of calendar/diary

Learn phone greeting (receptionist) - Written script displayed on desk to read when phone rings

Cognitive and work difficulties identified	Example CAT strategies used
Concerned about work speed (fast-food store)	- Requested shifts at ‘quieter’ periods, rather than at lunchtime ‘rush’
Punctuality/being late	- Training in use of alarm clock – setting early enough to catch bus
	- Leave curtain open at night so patient wakes with natural light
Grooming – pants too low, revealing buttocks (was given warning at work)	- Purchased new ‘higher’ waist pants
	- Established routine of ‘checking self’ in mirror before leaving home
Remembering tasks given (receptionist)	- Carry pen and notepad and write things down to remember
	- Training in use of calendar/diary
Learn phone greeting (receptionist)	- Written script displayed on desk to read when phone rings

In addition to external compensatory aids, as described earlier important components of CAT involved in vivo exposure, habitual skills practice, and practical support linking the participant with specialized services or external vocational agencies that could further meet their functional needs. These interventions were used frequently, and included support in using public transport, attending job interviews and practice in interviewing skills, attending career or educational interviews, linking in with community driving programs, or external employment agencies. On several occasions the CAT therapist provided information on cognitive functioning to external agencies to assist in subject/course selection, job searching, possible training requirements, adaptations to work or educational assessments, and driving recommendations.

Family involvement was common with four out of five families involved in information sharing during the initial CAT assessment. In most cases the goals of the participants corresponded to those identified by the CAT therapist, case manager and parents. However, occasionally parents or case managers identified additional goals, such as attention to personal hygiene or organization and cleanliness of the home environment. There was always collaborative discussion with the participant when this occurred, including how these areas of need related to functioning, including vocational functioning. Part of the CAT process was balancing the needs identified by the participant with those identified by their parents and ensuring engagement of the participant was at the forefront. Three of the five families (always parents) were also involved throughout the intervention period. This included assisting or reminding their family member with FEP to use the environmental supports and compensatory strategies implemented and being an additional source of feedback regarding the success or not of the particular interventions and providing new information as it arose. It was important to balance the hopes, identity and role of the caregiver with the young person’s own independence and specific goals. A clinical observation was that CAT appeared to reduce caregiver burden.

Young people adjusting to the experience and diagnosis of FEP may be particularly vulnerable to stigma, and thus may not be as willing (initially) to use visible environmental supports or have the CAT therapist be known to employers or educators [28]. This needs to be carefully assessed and considered when delivering CAT to ensure engagement is developed and maintained and that there is not excessive focus on the negative aspects of their condition. Thus, focusing on cognitive strengths and how these could be used to enhance daily functioning, in addition to cognitive difficulties was well received by the young FEP participants. For example, using picture-based prompts, rather than verbally-based prompts was helpful for some participants who had stronger visual skills. It may be more effective initially (or completely in some cases) to use ‘hidden’ or internal (i.e., mental) compensatory aids. Stigma appeared to be a significant concern for one participant in particular who was not receptive to the compensatory interventions suggested. There was also a significant adaptation process for some of the participants with respect to the marked derailment that having a psychotic disorder had on their educational or vocational pathway, with some of the participants having dropped out of school or courses and finding themselves re-evaluating the most appropriate and achievable vocational pathway based on their cognitive and symptomatic barriers. The CAT approach allowed for the provision of a theoretically-informed and positive framework to assist the participants who were grappling with these issues.

3.4 Formal outcome measures

With respect to vocational outcome, by the end of the CAT intervention four of the five participants were either working or studying (or doing both), while one participant remained unemployed. For this participant, the clinical impression was that despite attending most of the scheduled CAT sessions and having a primary goal of gaining employment, the combination of ongoing substance use (cannabis) and psychotic symptoms (hallucinations, paranoia, disorganization) interfered with the ability to engage effectively in CAT. While other participants also experienced psychotic symptoms during the CAT intervention, none of them used substances. Table 3 shows the mean scores on the formal outcome measures of functioning, quality of life and motivation before and after CAT. Most scores improved from baseline to post-intervention. The changes appeared to be largest for global functioning (SOFAS), UPSA Planning and Organization and quality of life domains of Physical Health, Psychological and Environmental

Table 3
Changes on formal measures of functioning, quality of life, and motivation following CAT (N = 5)

Outcome measure Baseline Post-CAT Change

Mean SD Mean SD Mean SD

Functioning

SOFAS 51.8 8.8 58.8 15.1 7.0 7.5

UPSA – Financial 16.2 2.8 15.6 1.8 –0.06 2.5

UPSA – Communication 9.4 1.3 9.2 4.3 –0.2 3.3

UPSA – Planning & Organization 11.8 3.1 15.0 4.2 3.2 3.6

UPSA – Transportation 14.6 4.4 15.2 3.4 2.8

UPSA – Household skills 16.0 2.2 14.0 5.5 –2.0 5.7

UPSA – Total 68.0 11.3 69.0 13.3 1.0 7.0

Quality of life

WHOQOL – Physical health 62.6 27.2 80.0 12.7 17.4 16.4

WHOQOL – Psychological 58.8 22.3 76.2 6.6 17.4 16.9

WHOQOL – Relationships 58.8 21.9 62.6 17.0 3.8 10.4

WHOQOL – Environmental 62.6 75.2 12.4 12.6 12.4

Motivation

BIS/BAS – Inhibition 17.6 2.7 19.0 2.3 1.4 2.2

BIS/BAS – Drive 9.4 4.5 12.4 3.8 3.0 5.4

BIS/BAS – Fun Seeking 9.4 4.2 10.8 3.3 1.4 2.7

BIS/BAS – Reward Responsiveness 14.6 5.9 17.6 0.9 3.0 6.4

Outcome measure	Baseline	Post-CAT	Change
Functioning
SOFAS	51.8	8.8	58.8	15.1	7.0	7.5
UPSA – Financial	16.2	2.8	15.6	1.8	–0.06	2.5
UPSA – Communication	9.4	1.3	9.2	4.3	–0.2	3.3
UPSA – Planning & Organization	11.8	3.1	15.0	4.2	3.2	3.6
UPSA – Transportation	14.6	4.4	15.2	3.4		2.8
UPSA – Household skills	16.0	2.2	14.0	5.5	–2.0	5.7
UPSA – Total	68.0	11.3	69.0	13.3	1.0	7.0
Quality of life
WHOQOL – Physical health	62.6	27.2	80.0	12.7	17.4	16.4
WHOQOL – Psychological	58.8	22.3	76.2	6.6	17.4	16.9
WHOQOL – Relationships	58.8	21.9	62.6	17.0	3.8	10.4
WHOQOL – Environmental	62.6	75.2	12.4	12.6	12.4
Motivation
BIS/BAS – Inhibition	17.6	2.7	19.0	2.3	1.4	2.2
BIS/BAS – Drive	9.4	4.5	12.4	3.8	3.0	5.4
BIS/BAS – Fun Seeking	9.4	4.2	10.8	3.3	1.4	2.7
BIS/BAS – Reward Responsiveness	14.6	5.9	17.6	0.9	3.0	6.4

Note. SOFAS = Social and Occupational Functioning Scale; UPSA = UCSD Performance-Based Skills Assessment; WHOQOL = World Health Organization Quality of Life; BIS/BAS = Behavioural Inhibition and Behavioural Activation Scales.

4 Discussion

This paper has reported on the goals and functional needs of five FEP individuals who participated in a pilot study of CAT. We have described how CAT can be used to address cognitive and functional impairments in young people with FEP, particularly in relation to vocational recovery. Despite the participants already receiving comprehensive evidence-based supported employment (IPS), a need for additional intervention addressing cognitive and functional impairments was clearly identified by the participants, their families and their treating team. We found that education and/or employment were key functional goals and therefore a strong focus of the CAT intervention. Furthermore, other functional areas targeted by CAT, which are requisite for successful work or educational outcomes, received significant attention, particularly organization and planning, transportation and ADL, such as hygiene/personal care. The need to focus on organization and memory was consistent with these cognitive domains being predictive of employment duration in a previous trial of IPS in FEP [6]. Along with the findings that CAT is a feasible and acceptable intervention in FEP [8], the clinical observations described herein suggests that further research of CAT for FEP either alone or in combination with vocational interventions are warranted.

Several informative observations emerged identifying adaptations and considerations for maximizing the benefits of CAT for young FEP clients. Regarding the use of compensatory strategies and environmental supports, the minimal use of technology (i.e., smartphones or Internet) was unexpected. A recent study of CAT in first-episode schizophrenia [29] and an SMS-prompting study in chronic schizophrenia [30] reported participant enjoyment and benefits from using mobile phones as a compensatory aid. We anticipated this would be prominent in CAT for FEP, as most Australian youth own a mobile phone [31] and use the Internet [32]. However, access and use of technology is influenced by socio-economic and education variables [32] and four out of the five participants in the current study were considered to be socio-economically disadvantaged. Furthermore, the one participant who owned a smartphone did not want to use it as a compensatory aid and preferred a paper-based calendar and diary. This participant reported that because paper-based was what they had been used to previously, they felt more comfortable with this. Thus, while the use of technology may be available, engaging, and beneficial for some FEP clients, this should not be assumed and traditional compensatory supports such as calendars, diaries, signs and checklists may be preferable. Nevertheless, we also learnt that careful consideration of the potential of stigma associated with implementing prominent environmental supports needs to occur, with a formal measure of stigma/self-stigma potentially being useful in future studies. Along this vein, the use of native and downloaded apps on smartphones as compensatory aids should remain a focus of further investigation, particularly given they are more discreet than other environmental supports [33]. Our observations also indicated that substance use may be a barrier to effective use of CAT and therefore, it is suggested that substance use be addressed first or simultaneously with CAT.

With respect to cognitive functioning, studies investigating engagement and utilization of ‘restorative’ cognitive remediation interventions have found that participants with higher cognitive abilities and fewer cognitive complaints engage better [34] and are more likely to improve [35] than those with lower abilities. These findings imply that compensatory and adaptive approaches may be best suited to those with larger cognitive impairments. Nevertheless, despite considerable cognitive heterogeneity in the current sample, four of the five participants rated CAT as a useful intervention and implemented strategies to assist them at school or work [8]. This may be because CAT focuses on the functioning goals of clients, rather than aiming to directly remediate cognitive impairment [36]. We suggest that variation in cognitive presentations needs to be carefully considered with respect to the type of compensatory strategies used, but this does not preclude any one individual from deriving benefit, as CAT is flexibly and individually tailored to the strengths and weaknesses of each client.

Our observations also indicated that CAT may be usefully added to or integrated with supported employment and education. While all participants had previously engaged with IPS, an additional focus on education and/or employment was identified as a priority in the CAT intervention. Furthermore, other functional areas targeted by CAT, which are requisite for successful work or educational outcomes, received significant attention in the current study, particularly organization and planning, transportation and hygiene/personal care. Potentially, CAT may enhance vocational outcomes by supporting the behaviours required to gain and maintain employment and education, which are often thwarted by cognitive impairment [6, 22].

In conclusion, there is ongoing need for developing and evaluating evidence-based interventions addressing cognitive and functional impairments in FEP. The clinical observations described herein, as well as the preliminary findings on the formal outcome measures, suggest that CAT may be a useful approach. However, this was clearly a small and uncontrolled exploratory study, tempering any assertions that can be made regarding the efficacy of CAT for FEP. Thus, the findings of this study may not be generalizable to all young people with psychosis. Larger controlled trials of CAT in FEP, possibly in combination with IPS, are needed to investigate thisfurther.

5 Conflict of interest

The authors have no conflict of interest to report.

6 Research ethics

Ethics approval was granted from the Melbourne Health Human Research Ethics Committee (#2011.120; 25 August 2011). All participants provided written informed consent after receiving a full explanation of the study. Data for the study were collected between January 2012 and February2013.

7 Funding

The study was funded by a University of Melbourne Early Career Researcher Grant, Orygen, The National Centre of Excellence in Youth Mental Health, and a Ronald Philip Griffiths Fellowship to K.A.

Footnotes

Acknowledgments

We thank Dr Shona Francey and Dylan Alexander for their clinical support and advice and Natalie Maples for her assistance. We also thank the EPPIC case managers for their support duringCAT.

References

Poon

MYC

, Siu

AMH

, Ming

. Outcome analysis of occupational therapy programme for persons with early psychosis. Work-a Journal of Prevention Assessment & Rehabilitation 2010;37(1):65–70.

Crain

, Penhale

, Newstead

, Thomson

, Heah

, Barclay

. The contribution of IPS to recovery from serious mental illness: A case study. Work-a Journal of Prevention Assessment & Rehabilitation 2009;33(4):459–64.

Rinaudo

, Ennals

. Mental illness, supported education, employment and recovery: Ben’s story. Work-a Journal of Prevention Assessment & Rehabilitation 2012;43:99–104.

Mesholam-Gately

, Giuliano

, Faraone

, Goff

, Seidman

. Neurocognition in first-episode schizophrenia: A meta-analytic review. Neuropsychology 2009;23(3):315–36.

Fett

A-KJ

, Viechtbauer

, Dominguez

M-d-G

, Penn

, Van Os

, Krabbendam

. The relationship between neurocognition and social cognition with functional outcomes in schizophrenia: A meta-analysis. Neuroscience and Biobehavioral Reviews 2011;35(3):573–88.

Allott

, Cotton

, Chinnery

, Baksheev

, Massey

, Sun

, Collins

, Barlow

, Broussard

, Wahid

, Proffitt

, Jackson

, Killackey

. The relative contribution of neurocognition and social cognition to 6-month vocational outcomes following Individual Placement and Support in first-episode psychosis. Schizophrenia Research 2013;150(1):136–43.

Mendella

, Burton

, Tasca

, Roy

, St Louis

, Twamley

. Compensatory cognitive training for people with first-episode schizophrenia: Results from a pilot randomized controlled trial. Schizophrenia Research 2015;162(1-3):108–11.

Allott

, Killackey

, Sun

, Brewer

, Velligan

. Feasibility and acceptability of cognitive adaptation training for first-episode psychosis. Early Intervention in Psychiatry. epub ahead of print 12 December 2014.

Velligan

, Ritch

, Maples

. Cognitive Adaptation Training: The Use of Compensatory Strategies in the Psychosocial Rehabilitation of Patients with Schizophrenia. 2nd ed. San Antonio, TX: UTHSC, Department of Psychiatry; 2010.

10.

Velligan

, Prihoda

, Ritch

, Maples

, Bow-Thomas

, Dassori

. A randomized single-blind pilot study of compensatory strategies in schizophrenia outpatients. Schizophrenia Bulletin 2002;28(2):283–92.

11.

Velligan

, Diamond

, Maples

, Mintz

, Li

, Glahn

, Miller

. Comparing the efficacy of interventions that use environmental supports to improve outcomes in patients with schizophrenia. Schizophrenia Research 2008;102, 312–9.

12.

Kidd

, Herman

, Barbic

, Ganguli

, George

, Hassan

, McKenzie

, Maples

, Velligan

. Testing a modification of cognitive adaptation training: Streamlining the model for broader implementation. Schizophrenia Research 2014;156(1):46–50.

13.

Velligan

, Bow-Thomas

, Huntzinger

, Ritch

, Ledbetter

, Prihoda

, Miller

. Randomized controlled trial of the use of compensatory strategies to enhance adaptive functioning in outpatients with schizophrenia. American Journal of Psychiatry 2000;157, 1317–23.

14.

Quee

, Stiekema

APM

, Wigman

JTW

, Schneider

, van der Meer

, Maples

, van den Heuvel

, Velligan

, Bruggeman

. Improving functional outcomes for schizophrenia patients in the Netherlands using Cognitive Adaptation Training as a nursing intervention - A pilot study. Schizophrenia Research 2014;158(1-3):120–5.

15.

Velligan

, Diamond

, Mueller

, Li

, Maples

, Wang

, Miller

. The short-term impact of generic versus individualized environmental supports on functional outcomes and target behaviors in schizophrenia. Psychiatry Research 2009;168(2):94–101.

16.

Velligan

, Diamond

, Mintz

, Maples

, Li

, Zeber

, Ereshefsky

, Lam

Y-WF

, Castillo

, Miller

. The use of individually tailored environmental supports to improve medication adherence and outcomes in schizophrenia. Schizophrenia Bulletin 2008;34(3):483–93.

17.

Ramsay

, Broussard

, Goulding

, Cristofaro

, Hall

, Kaslow

, Killackey

, Penn

, Comptom

. Life and treatment goals of individuals hospitalized for first-episode nonaffective psychosis. Psychiatry Research 2011;189(3):344–8.

18.

Iyer

, Mangala

, Anitha

, Thara

, Malla

. An examination of patient-identified goals for treatment in a first-episode programme in Chennai, India. Early Intervention in Psychiatry 2011;5(4):360–5.

19.

Addington

, Coldham

, Jones

, Ko

, Addington

. The first episode of psychosis: The experience of relatives. Acta Psychiatrica Scandinavica 2003;108(4):285–9.

20.

Jackson

, McGorry

, Henry

, Edwards

, Hulbert

, Harrigan

, Dudgeon

, Francey

, Maude

, Cocks

, Power

. Cognitively oriented psychotherapy for early psychosis (COPE): A 1-year follow-uBritish Journal of Clinical Psychology 2001;40, 57–70.

21.

Drake

, Bond

, Becker

. IPS Supported Employment: An Evidence Based Approach to Supported Employment. New York: Oxford University Press; 2012.

22.

Velligan

, Mahurin

, Diamond

, Hazleton

, Eckert

, Miller

. The functional significance of symptomatology and cognitive function in schizophrenia. Schizophrenia Research 1997;25, 21–31.

23.

McGurk

, Mueser

. Cognitive functioning, symptoms, and work in supported employment: A review and heuristic model. Schizophrenia Research 2004;70, 147–73.

24.

Goldman

, Skodol

, Lave

. Revising Axis-V for DSM-IV - A review of measures of social functioning. American Journal of Psychiatry 1992;149(9):1148–56.

25.

Patterson

, Goldman

. UCSD Performance-Based Skills Assessment (UPSA-2). San Diego, CA: University of California San Diego; 2005.

26.

World Health Organization. World Health Organization Quality of Life (WHOQoL-BREF), Australian Version. Geneva: Programme on Mental Health; 2000.

27.

Carver

, White

. Behavioral inhibition, behavioral activation, and affective responses to impending reward and punishment - The BIS/BAS scales. Journal of Personality and Social Psychology 1994;67(2):319–33.

28.

Allott

, Turner

, Chinnery

, Killackey

, Nuechterlein

. Managing disclosure following recent-onset psychosis: Utilizing the Individual Placement and Support model. Early Intervention in Psychiatry 2013;7(3):338–44.

29.

Hansen

, Ostergaard

, Nordentoft

, Hounsgaard

. The feasibility of Cognitive Adaptation Training for outpatients with schizophrenia in integrated treatment. Community Mental Health Journal 2013;49(6):630–5.

30.

Pijnenborg

GHM

, Withaar

, Brouwer

, Timmerman

, van den Bosch

, Evans

. The efficacy of SMS text messages to compensate for the effects of cognitive impairments in schizophrenia. British Journal of Clinical Psychology 2010;49, 259–74.

31.

Nielson. The Australian Internet&Technology Report 12th ed: Nielson; 2010.

32.

Ewing

, Thomas

. CCi Digital Futures Report: The Internet in Australia. Swinburne University of Technology, 2012.

33.

Migo

, Haynes

, Harris

, Friedner

, Humphreys

, Kopelman

. mHealth and memory aids: Levels of smartphone ownership in patients. Journal of Mental Health 2015;24(5):266–70.

34.

Gooding

, Saperstein

, Mindt

, Medalia

. Predictors of treatment utilisation at cognitive remediation groups for schizophrenia: The roles of neuropsychological, psychological and clinical variables. Neuropsychological Rehabilitation 2012;22(4):516–31.

35.

Medalia

, Richardson

. What predicts a good response to cognitive remediation interventions? Schizophrenia Bulletin 2005;31(4):942–53.

36.

Mueser

. Should psychosocial treatment for schizophrenia focus on the proximal or distal consequences of the disorder? Journal of Mental Health 2012;21(6):525–30.