Schizophrenia Research 166 (2015) 297–303

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Effects of integrated supported employment plus cognitive remediation training for people with schizophrenia and schizoaffective disorders Doreen W.H. Au a, Hector W.H. Tsang a,⁎, Wendy W.Y. So a, Morris D. Bell b, Vinci Cheung a, Michael G.C. Yiu c, K.L. Tam c, Gary Tin-ho Lee c a b c

Neuropsychiatric Rehabilitation Laboratory, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong Department of Psychiatry, School of Medicine, Yale University, United States Department of Psychiatry, United Christian Hospital, Hong Kong

a r t i c l e

i n f o

Article history: Received 25 November 2014 Received in revised form 29 April 2015 Accepted 4 May 2015 Available online 1 June 2015 Keywords: Integrated supported employment Work-related social skills training Cognitive remediation training Schizophrenia Vocational rehabilitation

a b s t r a c t Objectives: The present study aims to investigate the synergistic effects of cognitive remediation training (CRT) on Integrated Supported Employment (ISE). ISE blends individual placement support service with work-related social skills training for Chinese people suffering from schizophrenia or schizoaffective disorder. Method: Ninety participants with schizophrenia or schizoaffective disorders were recruited from two psychiatric outpatient services in Hong Kong. They were randomly assigned into the ISE + CRT (n = 45) and ISE (n = 45) conditions. Blinded assessments on vocational, clinical, psychological, and neurocognitive outcomes were conducted by independent assessors. The two groups were followed up at 7 and 11 months. Results: Both groups yielded similar improvements across several outcome domains assessed immediately after the interventions and at 7 and 11 month follow-ups, but no significant group differences were found. Significant positive trends over time in vocational, clinical and cognitive outcomes consistently favored the ISE + CRT condition. Conclusion: While both the ISE + CRT and ISE groups demonstrated improvement in vocational, clinical, psychological, and neurocognitive outcomes, there was no evidence to show that cognitive remediation facilitated further improvement in these domains beyond gains associated with ISE alone. Further investigation is needed to fully exploit the synergistic potential of ISE combined with CRT, and to better understand which individuals experience a maximal benefit from the specific rehabilitation program components. © 2015 Elsevier B.V. All rights reserved.

1. Introduction Individuals with severe mental illness (SMI) have an array of complex clinical and life problems. Problems in securing and maintaining employment have been of primary concern for researchers and practitioners alike because they undermine quality of life, reduce social networks, maintain poverty, limit insurance benefits, decrease recovery options, and reduce emotional, behavioral, and social well-being (Tsang et al., 2007). Helping people with SMI to obtain and sustain competitive employment is integral to improving their quality of life and facilitating their recovery (Strong, 1998; Tsang, 2003). Individual Placement and Support Service (IPS) has consistently demonstrated competitive employment outcomes superior to that of other vocational services for individuals with SMI. A review reported that the competitive employment rate of those receiving IPS was in ⁎ Corresponding author at: Neuropsychiatric Rehabilitation Laboratory, Department of Rehabilitation Sciences, the Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong. Tel.: +852 2766 6750; fax: +852 2330 8656. E-mail address: [email protected] (H.W.H. Tsang).

http://dx.doi.org/10.1016/j.schres.2015.05.013 0920-9964/© 2015 Elsevier B.V. All rights reserved.

the range of 47%–62%, as compared to about 25% for those who receive conventional and other types of vocational assistance (Bond et al., 2012). A more recent review showed employment rates between 58% and 60% for those receiving IPS, compared with 23%–24% for control conditions (Marshall et al., 2014). Recent replications in Switzerland using IPS yielded similar results with employment rates over 60% during a 5-year follow up period (Hoffmann et al., 2014). Our earlier studies on the Integrated Supported Employment model (ISE), which combines IPS and work-related social skills training (WSST), demonstrated a slightly higher competitive employment rate of 78.8% at the fifteenth month follow-up with job tenure averaging 24 weeks (Tsang et al., 2009). Other studies of IPS have yielded similar job tenure averages of between 17 and 30 weeks over 18-month to 2-year follow-ups (Bond et al., 2007; Bond and Kukla, 2011; Bond et al., 2012). A longer followup study showed an average job tenure of 32 months over 10-year follow-ups (Salyers et al., 2004). Although the employment rate using either IPS or ISE is impressive, the average job tenure is still far from satisfactory when compared with US and non-US general working populations, which averages 7–9 years (Sun et al., 2012; Bidwell, 2013). Our earlier job termination studies (Mak et al., 2006) found

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that interpersonal problems were commonly associated with short job tenure. This observation prompted our development of the combined approach of IPS and WSST and the creation of our augmented model of IPS that we called Integrated Supported Employment (ISE). ISE targets social competence and problem solving by using social skills training method ISE to boost vocational outcomes (Tsang, 2008). The landmark review by Green (1996) investigated the contribution that deficits in neurocognition make to poor community functioning (social and vocational) among those with schizophrenia. Our later review echoed the conclusion that cognitive ability is a significant predictor of employment outcomes, including work success, skill acquisition, and independent living among those with SMI (Tsang et al., 2010). Along the same line, another review which focuses on the interaction between supported employment services (SE) and cognitive functioning has pinpointed that provision of SE alone may improve some basic cognitive domains such as attention and psychomotor speed, but that it is more difficult to address impairments in higher order functions including working memory, verbal learning and memory, and executive function (McGurk and Mueser, 2004). Several later randomized controlled studies further demonstrated that SE in combination with cognitive remediation training (CRT) significantly maximized the positive employment outcomes of SE alone by 12 to 24 months (McGurk et al., 2005; Bell et al., 2008). In the present study, we take a step further by exploring whether improving neurocognitive functions by CRT can boost vocational outcomes beyond what integrated social skill training can do in our ISE program. We hypothesize that CRT may improve vocational outcomes, because improved cognitive capacity may allow participants in ISE to better utilize the social skills training and other rehabilitation interventions, as well as to perform better at work. This combination of interventions has not been explored in the literature and has never been attempted in an Asian country. We built upon our earlier work to develop a state-of-the-art model of supported employment which combines IPS, WSST and CRT. We hypothesize that vocational, clinical, psychological and neurocognitive outcomes would be further improved with this innovative approach. 2. Material and method 2.1. Participants Ninety eligible participants from two local psychiatric out-patient clinics or day hospitals were recruited between April 2011 and April 2013. Participants were ages 18 and older with a DSM-IV-TR diagnosis of schizophrenia or schizoaffective disorder as confirmed by the Chinese Version Structural Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders IV (So et al., 2005). Participants were in various stages of rehabilitation at the time of recruitment, but were excluded if they had moderate or greater cognitive impairment. These excluded participants that had a score of greater than 18 on the 30-item Mini-Mental State Examination (Chiu et al., 1994) and/or were not mentally capable of giving informed consent. Participants were currently unemployed, and had competitive employment as their current vocational goal. 2.2. Measures The primary outcome measures were employment rate and job tenure as measured by the employment outcome checklist (Tsang et al., 2002). Secondary measures included the 18-item Brief Psychiatric Rating Scale (BPRS) (Overall and Gorham, 1962); the Global Assessment of Functioning (GAF) (American Psychiatric Association, 2000); the Chinese version of Personal Well Being Index—Adult (PWI) (Lau et al., 2005), and the Rosenberg Self-esteem Scale (RSES). Executive functioning was measured by the Wisconsin Card Sorting Test (WCST) (Heaton et al., 1981). Five cognitive domains were measured by MATRICS

Consensus Cognitive Battery (MCCB) (Green et al., 2004), which included speed of processing, attention/vigilance, visual learning and memory, reasoning and problem solving, and social cognition. Verbal learning and working memory were measured in three stages of information processing by the Hong Kong List Learning Test (HKLLT) 2nd Edition (Chan et al., 2000; Chan, 2006). 2.3. Procedures After giving informed consent, participants were randomly assigned to either the ISE + CRT group (n = 45) or the ISE group (n = 45) by a blinded research assistant based on random assignment generated by SPSS. The ISE component followed the protocol described in our previous studies (Tsang, 2003). Six out of seven core features of the IPS were incorporated with the exception of the rapid job search. Instead, ten WSST sessions (1.5–2 h per week) were conducted in group format prior to job search. Individualized ongoing support was given on an unlimited time basis within the study period after participants obtained employment. Participants in the ISE + CRT program received, in addition to ISE, 6 h (2-hour session, 3 sessions) per week of individualized, visual-based computer-assisted cognitive exercises by two cognitive remediation software systems [Strong arm system (StrongArm, 2007), a 2-hour session once per week; and Captain's Log (Sandford and Browne, 1988), 2-hour session twice per week]. A TV watching session was added on top of the ISE group as a control to neutralize the effect of additional time and therapist contact due to CRT in the ISE + CRT group. Both groups underwent 12 weeks (i.e., 3 months) of training sessions prior to job search, so that an individual could have a maximum of 72 h of cognitive training. Assessments were conducted before and after the completion of the three-month augmentation service, and follow-ups were done at 7 and 11 months after that service, and were performed by independent, trained, and blind assessors. 2.3.1. Analysis Baseline comparisons were performed by t-test or Chi-square to detect between-group differences. The Mann–Whitney U tests or McNemar tests were used where appropriate. Given the balanced design, repeated measures ANOVAs with post-hoc analyses were used to determine if significant differences occurred at different points in times of the study. Wilcoxon tests or Friedman tests were used to assess within-group differences if parametric assumptions were not met. Competitive employment referred to jobs in the community, either full-time or part-time, that were open to any individuals (Mak et al., 2006). Success in competitive employment was defined as having continuously worked in a job for two or more months for at least 20 h per week. The employment rate we reported at different follow-up periods was the cumulative rate. Job tenure was defined as the longest duration of employment sustained during the study. All participants were included in analyses following the ‘Intent-to-treat’ principle, with the last observation carried forward to replace any missing data. Significant levels were set at p b 0.05 for all analyses with Bonferroni adjustments made with the p-values where appropriate. 3. Results Both the ISE + CRT and ISE participants on average attended over 70% of the 12-week training sessions with no significant between-group differences (χ2 = 0.56, df = 1, p = 0.405). The program attrition rate was 11.11% with 8.9% for the ISE + CRT group and 13.3% for the ISE group (χ2 = 0.45, df = 1, p = 0.502). No group differences in demographic data and baseline clinical outcomes were found as seen in Table 1. 3.1. Vocational outcomes Among ninety participants, 44.4% of ISE + CRT participants and 55.6% of ISE participants successfully obtained competitive employment

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by the month follow-up but no significant between-group differences were found (Fig. 1). A greater proportion of ISE + CRT participants (60%) worked full time compared to ISE participants (52%). The majority of the participants worked at entry-level jobs such as security guard, cleaning worker, shop assistant, clerk, and delivery worker. There were significant within-subject differences for job tenure (ps b 0.05) from the 7th month to 11th month but did not differ by condition. No significant between-group differences were found at any period although we observed that the ISE + CRT participants worked longer in a job, received more than the minimum hourly wage of HK$30, and had fewer numbers of job terminations than the ISE group at the 11th month.

(Table 3). However, both the ISE + CRT and ISE conditions revealed significant positive time trend effects for all neurocognitive outcomes (all with p's b 0.05) with the exception of social cognition and two working memory domains. Negative significant time trend effects were observed for the social cognition domain (p b 0.001) and the retention stage of working memory (p b 0.001) in both groups. No significant time trend was observed at the retrieval stage of working memory. Post hoc test further revealed a marginally significant group difference in visual learning immediately after the intervention, with higher scores in the ISE + CRT group than the ISE group at the post-assessment period (p b 0.025, with Bonferroni correction).

3.1.1. Clinical and psychological outcomes Analysis on the GAF scores showed a marginally significant group– time interaction effect up to the 11th month follow up as indicated in Table 2 [F(3, 264) = 3.05, p = 0.05]. Post hoc t-tests revealed a significant upward time trend in GAF for both groups throughout the 11th month period (p b 0.05) with higher GAF scores observed in the ISE group, but no significant between-group differences at all time intervals (all with p N 0.0125 with Bonferroni correction). Both the ISE + CRT and ISE groups showed a gradual improvement in symptoms on the BPRS up to the 11 month follow up (p b 005). The interaction effects of group over time were not significant in personal well-being [F(3,264) = 0.106, p = 0.956] and self-esteem [F(3,264) = 1.606, p = 0.195]. There were increases in self-reported personal well-being and selfesteem for both groups with slightly higher scores in the ISE group, but the time trend was marginally significant in self-esteem scores (p = 0.05).

4. Discussion

3.2. Neurocognitive aspects No between-group differences or interaction effects were found across all neurocognitive outcomes throughout the 11 month period

The present study aims to investigate the synergistic effects of CRT on the ISE which blends IPS with WSST for Chinese people suffering from schizophrenia or schizoaffective disorder. While both the ISE + CRT and ISE groups demonstrated sustained improvements in vocational, clinical, psychological, and neurocognitive outcomes, there was no evidence in this study that cognitive remediation facilitated further improvements in these domains above and beyond gains associated with the ISE stand-alone program. In general, our main hypothesis that ISE combined with CRT augments vocational, clinical and cognitive domains is not supported. Even so, the current study is the first to compare these treatment strategies with SMI in the Chinese community. This provides preliminary evidence that similar approaches using ISE and/or CRT will significantly improve both the vocational and non-vocational outcomes of Chinese populations with SMI, which constitutes 16 million individuals in China (Chen, 2011). As to our primary outcomes of this study, the addition of CRT component did not further enhance the employment rate and the job tenure of the ISE program as expected. Both the ISE + CRT and ISE programs

Table 1 Demographic characteristic and baseline clinical outcomes of participants. Variables

Gender Male Female Marital status Single Married Divorced Widowed Separated SCID Schizophrenia Schizoaffective disorder Employment history Yes No Recruitment sites OK UCH

Age Years of education (First year = K1) Age at diagnosis Age of first hospitalization ISECRT (n = 39); ISE (n = 35) Number of previous hospital admissions ISECRT (n = 45); ISE (n = 44) Duration of illness (years) MMSE (0–30) BPRS (0–126) GAF (0–100)

ISE + CRT (N = 45)

ISE (N = 45)

n

%

n

%

χ2

p-Value

28 17

62.22% 37.78%

29 16

64.44% 35.56%

0.048

0.827

40 1 3 0 1

88.89% 2.22% 6.67% 0.00% 2.22%

39 2 3 1 0

86.67% 4.44% 6.67% 2.22%

2.346

0.672

29 16

64.44% 35.56%

23 22

51.11% 48.89%

1.64

0.286

44 1

97.78% 2.22%

43 2

95.56% 4.44%

0.345

0.557

21 24

46.67% 53.33%

18 27

40.00% 60.00%

0.407

0.523

Mean

S.D.

Mean

S.D.

t

p-Value

−0.771 0.203 −0.968 −0.974 0.259 0.148 1.074 0.082 −0.490

0.443 0.840 0.336 0.333 0.796 0.883 0.286 0.935 0.625

35.38 15 24.04 24.10 2.38 11.33 28.07 23.78 60.64

9.20 2.71 7.51 7.29 2.28 8.87 1.75 3.25 7.34

36.89 14.89 25.8 25.97 2.25 11.08 27.58 23.71 61.47

9.40 2.48 9.58 9.18 2.37 6.62 2.37 4.42 8.53

Note: ISE, integrated supported employment; CRT, cognitive remediation training; SCID, the Chinese Version Structural Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders IV (SCID—Chinese Version); BPRS, brief psychiatric rating scale; GAF, the global assessment of functioning scale; OK, psychiatric daycare service of the Baptist Oi Kwan; UCH, the outpatient clinic of United Christian Hospital; Employment history is an indicator of any working experiences prior to the study.

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b) Job tenure

0.6

55.60% 44.40%

0.4 28.90%

0.3

ISE+CRT

22.20%

ISE

0.2 0.1 0 At 0month

At 3month

At 7month

12 10

8.51 8.65

8 ISE+CRT

6

ISE

4 2 0 At 0month

c) Salary

At 3month

At 7month

At 11month

d) No. of job termination

45

42.29

40

Hourly wage ($)

13.29 12.87

14

At 11month

35.99 34.59

35

36.32

30 25 ISE+CRT

20

ISE

15 10 5 0 At 0month

At 3month

At 7month

Average no. of job termination

Percentage

0.5

Longest job tenure ( in weeks)

a) Employment rate

0.4 0.35

0.35 0.3

0.24

0.25

0.24

0.2

ISE+CRT 0.15

0.15

ISE

0.1 0.05 0

At 11month

At 0month

At 3month

At 7month

At 11month

Fig. 1. Comparison of vocation outcomes between ISE + CRT and ISE groups. Notes: CRT, cognitive remediation therapy; ISE, integrated supported employment. Job tenure, salary, and number of job termination were based on a total of 45 participants (ISE + CRT: n = 20; ISE: n = 25) who were employed at any follow-up time intervals up to 11th months. Chi-square or Mann–Whitney U tests were used for between-group differences. McNemar test or Wilcoxon tests were used for within-group differences. There were significant within-group differences for job tenure (ps b 0.05) from the 7th month to 11th month for both groups. No significance differences were found for other measures.

showed improvement in vocational outcomes, with competitive employment rates in the range of 44–56% at the 11 month follow-up. The improved employment rates at one year follow-up are comparable to

the findings from western countries which focused on the addition of CRT components to the IPS program (Bell et al., 2012). Both groups showed improvement in all other vocational outcomes with a significant

Table 2 Comparison of clinical and psychological outcomes between ISE + CRT and ISE groups. Mean + SD

Effect Group

ISE + CRT Clinical aspect GAF

BPRS

Psychological aspect PWI

RSES

ISE

p

Pre-assessment Post-assessment FU at 7th month FU at 11th month Pre-assessment Post-assessment FU at 7th month FU at 11th month

60.64 ± 7.34 61.76 ± 8.39 61.89 ± 10.08 62.22 ± 10.83 24.16 ± 3.88 22.49 ± 3.38 22.87 ± 4.22 22.38 ± 3.19

61.47 ± 8.53 63.33 ± 10.43 64.98 ± 10.21 68.16 ± 11.56 23.73 ± 4.09 22.89 ± 3.79 22.89 ± 3.72 22.36 ± 3.84

0.63 0.43 0.15 0.01 0.62 0.60 0.98 0.98

Pre-assessment Post-assessment FU at 7th month FU at 11th month Pre-assessment Post-assessment FU at 7th month FU at 11th month

54.92 ± 14.26 56.60 ± 14.61 56.60 ± 14.10 56.60 ± 14.10 25.69 ± 4.00 25.89 ± 4.35 26.02 ± 4.09 25.27 ± 4.89

54.25 ± 18.87 56.76 ± 18.84 57.08 ± 16.45 57.08 + 16.45 25.27 ± 4.24 25.87 ± 4.00 26.31 ± 4.13 26.82 ± 4.07

0.85 0.96 0.88 0.88 0.63 0.98 0.74 0.11

Time

Group × time

F

p

F

p

F

p

2.73

0.10

7.14

0.00

3.05

0.05

0.00

0.99

7.08

0.00

0.43

0.73

0.00

0.95

1.55

0.20

0.11

0.96

0.07

0.80

2.72

0.05

1.61

0.19

Notes: CRT, cognitive remediation therapy; ISE, integrated supported employment; GAF, the global assessment of functioning scale; BPRS, brief psychiatric rating scale; PWI, personal wellbeing index; RSES, the Rosenberg self-esteem scale p value ≤ 0.05 are shown bold.

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Table 3 Comparison of neurocognitive outcomes between ISE + CRT and ISE groups. Mean + SD

Effect Group

WCST Perseverative errors

Conceptual level response

MCCB Speed of processing

Attention/vigilance

Visual learning

Reasoning and problem solving

Social cognition

HKLLT Total Learning

Retention

Retrieval

Time

ISE + CRT

ISE

p

F

p

Pre-assessment Post-assessment FU at 7th month FU at 11th month Pre-assessment Post-assessment FU at 7th month FU at 11th month

47.73 ± 8.91 50.71 ± 11.58 51.76 ± 8.72 51.64 ± 10.47 37.16 ± 10.90 41.56 ± 10.74 43.82 ± 9.57 44.71 ± 10.15

48.40 ± 12.75 50.40 ± 13.08 52.16 ± 12.97 53.47 ± 14.33 35.42 ± 11.63 37.64 ± 12.88 41.04 ± 12.43 42.84 ± 12.51

0.77 0.91 0.86 0.49 0.47 0.12 0.24 0.44

0.09

0.77

1.64

Pre-assessment Post-assessment FU at 7th month FU at 11th month Pre-assessment Post-assessment FU at 7th month FU at 11th month Pre-assessment Post-assessment FU at 7th month FU at 11th month Pre-assessment Post-assessment FU at 7th month FU at 11th month Pre-assessment Post-assessment FU at 7th month FU at 11th month

36.38 ± 15.49 36.96 ± 11.51 37.51 ± 10.59 48.56 ± 30.55 37.56 ± 12.56 41.77 ± 12.41 40.84 ± 13.44 42.74 ± 13.09 42.27 ± 13.21 47.73 ± 14.23 42.44 ± 16.54 42.71 ± 15.97 39.27 ± 9.94 38.51 ± 9.08 42.57 ± 13.96 41.96 ± 12.22 29.20 ± 9.28 28.18 ± 9.05 26.84 ± 11.25 27.04 ± 10.36

34.24 ± 11.33 44.64 ± 39.75 39.58 ± 11.25 44.80 ± 24.58 34.87 ± 11.17 38.22 ± 11.09 39.04 ± 12.70 39.24 ± 13.14 38.07 ± 11.06 41.53 ± 11.50 40.76 ± 14.89 40.04 ± 13.02 38.62 ± 9.30 39.29 ± 9.89 44.54 ± 13.00 43.51 ± 11.17 30.09 ± 10.27 28.76 ± 9.72 25.73 ± 10.50 28.67 ± 10.45

0.46 0.22 0.37 0.52 0.31 0.16 0.73 0.38 0.11 0.03 0.61 0.39 0.75 0.70 0.49 0.53 0.67 0.77 0.63 0.46

Pre-assessment Post-assessment FU at 7th month FU at 11th month Pre-assessment Post-assessment FU at 7th month FU at 11th month Pre-assessment Post-assessment FU at 7th month FU at 11th month

21.24 ± 6.25 25.04 ± 6.99 25.76 ± 6.71 27.20 ± 7.32 2.51 ± 2.52 2.11 ± 2.30 2.20 ± 2.25 2.02 ± 2.26 6.64 ± 6.39 6.41 ± 5.85 6.53 ± 5.70 5.51 ± 3.61

20.67 ± 6.40 22.64 ± 6.38 24.56 ± 6.76 24.22 ± 6.48 2.42 ± 2.04 1.73 ± 2.31 1.93 ± 2.28 1.33 ± 2.56 7.16 ± 2.81 6.58 ± 2.78 6.53 ± 2.95 7.33 ± 6.41

0.67 0.09 0.40 0.04 0.85 0.44 0.58 0.18 0.46 0.86 1.00 0.10

F

Group × time p

F

p

9.00

0.00

0.44

0.72

0.20

18.90

0.00

0.43

0.73

0.11

0.74

5.29

0.00

1.50

0.21

1.49

0.23

8.96

0.00

0.34

0.79

2.23

0.14

4.30

0.01

1.15

0.33

0.20

0.65

12.30

0.00

0.67

0.57

0.07

0.79

5.13

0.00

0.88

0.45

2.04

0.16

33.37

0.00

2.22

0.10

0.83

0.37

3.79

0.01

0.55

0.65

0.81

0.37

0.34

0.795

1.28

0.28

Notes: CRT, cognitive remediation therapy; ISE, integrated supported employment; WCST, Wisconsin Card Sorting Test; MCCB, MATRICS Consensus Cognitive Battery; HKLLT, the Hong Kong List Learning Test (HKLLT) 2nd Edition. All WCST and MCCB measures are in T scores. p value ≤ 0.05 are shown bold.

time trend revealed in job tenure. These findings suggest that both ISE + CRT and ISE alone are effective at improving job tenure for the target group. Both the ISE and ISE + CRT groups showed improvements in cognitive performances with higher scores observed in the ISE + CRT group than ISE group. The findings were consistent with the literature (McGurk and Mueser, 2004) that the addition of CRT might improve higher order functioning, for which IPS or ISE cannot fully compensate. Contrary to the review by Grynszpan et al. (2011), we found a decreasing performance on social cognition domain in the ISE + CRT group. Our findings on the negative changes of the social cognition domain might reflect the distinctiveness of neurocognition and social cognition that have been reported in a recent systematic review (Mehta et al., 2013) and our earlier path analysis (Bell et al., 2009). One possibility is that both the ISE and ISE + CRT treatment did not specifically address the emotional component of social cognition that the MCCB intended to assess even though the emotion management subscale has been recommended by the MATRICS committee as the sole measure of social cognition to be employed in clinical trials of cognitive enhancement in schizophrenia (Eack et al., 2010). Another possibility might be due to the cultural differences between Asians and North Americans

in managing interpersonal situations. This may imply that the scoring method and the norms might not be valid in the Hong Kong context. Given that only one study has validated the social cognition part of the MCCB among Taiwanese (Ma et al., 2010), further cross culture validations of this instrument would shed light on possible causes for the differences. Given the widely accepted notion that social cognition mediates neurocognition and vocational performance of those with severe mental illness (Green and Horan, 2010), further analysis on the addition of social cognition training in vocational context is recommended. The ISE group showed better psychological, social and occupational functioning, and higher self-esteem and personal well-being than the ISE + CRT group, but no significant group differences were found. These results echoed well with recent findings that cognitive remediation treatment produced sustained improvements in neurocognitive domains, but little improvement on the global functioning, quality of life, and self-esteem (McGurk et al., 2007; Bowie et al., 2012; Garcia-Fernandez et al., 2014). Both groups showed similar improvement in clinical symptoms and hence further studies are needed to confirm if the addition of CRT to the ISE program has the potential to further improve the clinical symptoms in the long run.

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This study had a number of limitations. First, non-significant findings might have been attributed to the plateau effect induced by the WSST component as it has already pushed the effects to the upper limit. When CRT was integrated, it makes sense that the effects may not be further boosted significantly. Second, the non-significant findings might be due to the small sample size even though the number of participants exceeded our a priori sample size estimation. We believe that if the sample size is increased and if we limited our participants to those with more severe cognitive impairments, the enhancement effect of CRT on the ISE program may be more readily manifested. Finally, the optimal design for examining the synergistic effects between the two augmentations to IPS would have been a four cell study comparison: 1) ISE and placebo; 2) ISE and CRT; 3) CRT and SE and 4) SE., even though a much larger sample size would be required. Nonetheless, the two cell approach used in this study can still provide new and important insight on the integrated vocational rehabilitation programs. Addition of CRT to the ISE program might produce more noticeable effects if we target people with more severe nerocognitive impairment, but further investigation is needed to fully exploit the synergistic potential while avoiding the interference of detrimental effects of one program component with the favorable impact of the other component as noted by Bucci et al. (2013). Another study (Bell et al., 2012) found that CRT augmentation to IPS improved vocational outcomes for those with poor community function at baseline but was not necessary for those with better community functioning. Such studies indicate that more needs to be learned about personalizing rehabilitation so that the best combination of services can be determined based on individual characteristics. Addressing these questions is essential to the design of the integrated program for vocational rehabilitation practice. Role of funding source This study was funded by a grant from the Health and Medical Research Fund Committee (formally Health and Health Services Research Fund; HHSRF Project No.: 08091201). The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.

Contributors HT, MB, VC, MY, and KT conceptualized the study. HT wrote the proposal with assistance from MB which was eventually funded. KT, WY, and GL aided in managing the recruitment process. DA carried out analysis and wrote the first draft of the manuscript. HT and MB critically revised the manuscript. WS provided administrative support on data analysis. HT oversaw the study as a principal investigator of the project. All authors contributed to and approved the final version of the manuscript. Conflicts of interest All authors declare that they have no conflicts of interest.

Acknowledgments We are grateful to the psychiatric service units of the Baptist Oi Kwan and United Christian Hospital from which we recruited the subjects.

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Effects of integrated supported employment plus cognitive remediation training for people with schizophrenia and schizoaffective disorders.

The present study aims to investigate the synergistic effects of cognitive remediation training (CRT) on Integrated Supported Employment (ISE). ISE bl...
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