Learning medication self-management skills in schizophrenia: Relationships with cognitive deficits and psychiatric symptoms

aE~IAVIOa T ~ . P Y 25, 5-15, 1994

Learning Medication Self-Management Skills in Schizophrenia:

Relationships with Cognitive Deficits and Psychiatric Symptoms

PATRICK W . CORRIGAN

University of Chicago, Pritzker School of Medicine

CHARLES J . WALLACE

UCLA Clinical Research Center for Schizophrenia and Psychiatric Rehabilitation

MARK L. SCI-IADE

Austin State Hospital, Austin, TX

MICHAEL F. G ~ E ~

UCLA Clinical Research Center for Schizophrenia and Psychiatric Rehabilitation

Previous research has shown that the psychosocial skill learning of patients with schizophrenia is associated with several aspects of information processing. These processes may limit the effectiveness of skills training. The contributions of visual vig- fiance, verbal memory, conceptual flexibility, and psychiatric symptoms to medication self-management skill learning were examined in 30 subjects with schizophrenia. Results showed that skill learning was significantly associated with recall memory and visual vigilance but not with conceptual flexibility. Additional analyses showed that skill learning was not related to psychotic symptoms; nonsignificant trends were found with an index of negative symptoms. These findings may help clinical investigators develop cognitive rehabilitation strategies that facilitate psychosocial skill learning for this population.

The authors thank Sally MacKain, Patty Parlier-Cook, and Daniel Storzbach for help in data collection. The sample was obtained through the excellent cooperation of the staff and administration of Camarillo State Hospital. Funding for this project came from NIMH Grant MH-43292 to Dr. Green. Diagnostic training and symptom assessment were supported by NIMH Clinical Research Grant MH-30911 (R.P. Liberman, P.I.). The software for the Continuous Performance Test and Span of Apprehension was developed by Drs. Keith Nuechterlein and Robert Asarnow with support from the John D. and Catherine T. MacArthur Foundation Network for Risk and Protective Factors in Major Mental Disorders. Address all correspondence to Patrick Corrigan at the University of Chicago, Center for Psychiatric Rehabilitation, 7230 Arbor Drive, Tiniey Park, IL 60477.

5 0005-7894/94/0005-001551.00/0 Copyright 1994 by Association for Advancement of Behavior Therapy

All rights of reproduction in any form reserved.

6 CORRIGAN ET AL.

The psychosocial deficits of schizophrenia are vast and pervade all stages of the illness (Avison & Speechley, 1987; Klorman, Strauss, & Kokes, 1977). Various skills training methods have been developed to remediate these deficits by increasing the patient's repertoire of interpersonal and coping skills. Pa- tients have been trained on a range of specific skills, including basic conversation, interpersonal problem solving, and medication management. In the pro- totypical skills training paradigm, trainers provide succinct statements regarding the skills to be learned, model these skills, facilitate role-plays of the targeted behaviors, provide feedback regarding the role play, and reinforce successive approximations to the targeted behaviors. Hence, participants must be able to look, listen, and practice from verbal instructions, demonstrations, and role- play situations.

Research has shown that many patients who participate in skills training are able to improve their repertoire of interpersonal and coping behaviors (Bel- lack, Turner, Hersen, and & Luber, 1984; Hansen, St. Lawrence, & Christoff, 1985; Liberman, Mueser, & Wallace, 1986). Unfortunately, some patients are unable to acquire targeted behaviors in traditional skills training programs (Liberman, Massel, Mosk, & Wong, 1985; Massel, Corrigan, Liberman, & Milan, 1991; Wong & Woolsey, 1989). In cases like these, clinical investigators have often sought to identify treatment limitations in terms of the intervention itself; e.g., dismantling research designs that examine which components of an intervention have no impact on patients. Alternatively, limitations in social skills training may be explained by individual differences that interact with treatment procedures to produce treatment response or lack thereof. Two domains of person variables-information-processing deficits and psychiatric symptoms-may be especially relevant for understanding the effects of interpersonal and coping skills training for patients with schizophrenia.

Several investigations have examined the interrelationship of information processing and skill learning. Two studies found significant correlations between measures of visual vigilance and skill learning. Bowsen et al. (1989) showed that short-term (within session) acquisition of medication management skills was significantly associated with visual vigilance as measured on the Degraded-Stimulus Continuous Performance Test (DS-CPT). Similarly, Kern, Green, and Satz (1992) found that DS-CPT performance predicted acquisition and maintenance of symptom-management skills. Two studies also demonstrated that skills training was significantly predicted by short-term recall memory (Bowen et al., 1989; Kern et al., 1992; Mueser, Bellack, Douglas, & Wade, 1991). Bowen and her colleagues (1989) found visual vigilance and recall memory to be independently correlated with skill learning.

The manner in which psychiatric symptoms affect skill learning has also been examined. Negative symptoms that include social and emotional withdrawal have been shown to predict psychosocial skill learning in this population. Bellack, Morrison, Mueser, and Wade (1989) demonstrated that patients with negative symptoms produced lower scores on measures of social skill and role functioning than did a comparison group not exhibiting extreme social withdrawal. Interestingly, research has suggested that skills training is rela- tively unrelated to level of psychotic symptoms (Eckman et al., 1992).

COGNITIVE DYSFUNCTIONS AND PSYCHOSOCIAL SKILL LEARNING 7

The present study included three components designed to explore the inter- action between person variables and medication self-management skill learning: (1) refined measure of skill learning (a comprehensive instrument that assesses the component microprocesses of skill learning- ability to learn from specific tasks such as instructions, videotape, and role p l ay - was adopted for the current study) (Bowen et al., 1989); (2) a broader array of sensitive and valid information-processing measures, including assessments of visual vigilance, iconic memory, recall memory, and conceptual flexibility; and (3) measures of thinking disturbance (psychotic symptoms) and withdrawal/retardation (negative symptoms) to determine their relationships with skill learning.

Method

Subjects Thirty inpatients with DSM-III-R diagnoses of schizophrenia from Cama-

rillo State Hospital in southern California participated in this study. These subjects were drawn from a much larger, concurrent study on information processes in schizophrenia (Michael Green, Principal Investigator). Patient diagnoses were validated by completion of an expanded version of the Present State Exam (Wing, Cooper, & Sartorius, 1974); diagnoses were supported if subjects endorsed the criterion level of items specific to schizophrenia. Clini- cians conducting the interviews were trained to a minimum agreement of 85 % for the presence of symptoms according to criterion ratings of the Diagnosis and Psychopathology Unit of the Clinical Research Center for the Study of Schizophrenia at UCLA (Robert P. Liberman, principal investigator). The sample also demonstrated at least a fourth-grade reading level on the Wide Range Achievement Test-Revised (Jastak & Wilkinson, 1984) and had cor- rected vision of at least 20/30 on the Snellen eye chart (Graham Field, 1993).

The sample was ?6.?% male, was 34.0 years of age on average (SD = ?.6), and had completed 11.4 years of education (SD = 1.6). Age was not significantly related to skill learning and cognitive measures. The average age at first hospi- talization was 19.0 years (SD = 4.5), and the number of years since first hos- pitalization was 14.3 years (SD = 6.5). The average level of patients' neuroleptic medications equaled 1299 rag. chlorpromazine equivalents (SD = 814) (Davis, 1974). There were no significant correlations between chronicity and medication levels versus measures of cognition or skill learning.

Dependent Measures Subjects completed measures of both medication self-management skill

learning and information processing and were administered an interview for psychiatric symptoms.

Medication self-management skill learning. Skill learning was assessed using the Medication Management Test (MM'I~, Bowen et al., 1989), which was mod- ified from evaluation instruments used to evaluate the Medication Management Module developed by the UCLA Clinical Research Center for Schizophrenia and Psychiatric Rehabilitation. The module provides a highly structured cur- riculum designed to train patients with chronic schizophrenia on interpersonal

8 CORRIGAN ET AL.

skills (e.g., how to negotiate with health-care professionals about changing medications) and coping behaviors (e.g., self-monitoring strategies to track side effects) necessary to become more independent in their use of neuroleptic medication. Previous research has shown that patients who participated in this module showed significant increments in medication self-management skills (Eckman, Liberman, & Phipps, 1990; Eckman et al., 1992; Wallace, Liberman, MacKain, BlackweU, & Eckman, 1992).

The examiner read two paragraphs to the subject to assess comprehension of verbal instructions during the first task of the MMT. Individuals then an- swered four questions after each paragraph that assessed mastery of the material. Questions were repeated once when necessary. Subjects' answers were recorded verbatim by the examiner, rated as correct (1 point) or incorrect (0 points) by two independent judges, and summed to produce a total score.

To assess learning from demonstration, subjects viewed five 3-minute vignettes that provided visual and auditory presentation of medication self- management skills. The vignettes were followed by one or two open-ended questions that assessed the subject's comprehension of the material. As in the previous task, responses were recorded verbatim, subsequently scored as correct or incorrect by two judges, and summed to yield a single score. Finally, to assess procedural learning of specific behaviors, subjects viewed for a second time one videotaped segment in the previous set that demonstrated the six steps of correct self-administration of medication. Subjects were then asked to repeat the steps in a role play with the examiner. The role play was videotaped, later scored for the presence of absence of each step by judges, and summed to obtain a total role-play score. Interrater reliability of 75~/0 of the videotaped role plays was determined.

Information processing. Five well-validated tests were included to measure information-processing functions; these tests were the Degraded-Stimulus Con- tinuous Performance Test (DS-CPT), the forced choice Span of Apprehen- sion Test (SPAN), the Digit Span Distractibility Test (DSDT), the Rey Audi- tory Verbal Learning Test (RAVLT), and the Wisconsin Card Sorting Test (WCST).

The DS-CPT is a measure of visual vigilance (Nuechterlein, 1983) and was assessed using Version 1 of the UCLA CPT computer program (Nuechterlein & Asarnow, 1987). The DS-CPT was presented on an IBM-PC computer with a Taxan 720 color monitor. Viewing distance was one meter, and subjects responded by pressing the appropriate button on a Gravis joystick; subjects were instructed to press a response button whenever they saw the target number 0. Numbers were degraded to a standardized degree by reversing the black/white setting of a random 400 of pixels. Stimulus degradation places a burden on the early encoding state of information processing. Subjects were shown 160 practice trials followed by 480 experimental trials presented in three blocks of 160. Stimuli were presented for 60 ms at 1-second intervals for all trials. The target 0 appeared in quasirandom sequence 20 out of every 80 trials. A', a nonparametrie signal detection index of sensitivity (the ability to discriminate targets from nontargets), was determined from patients' responses.

The SPAN is an index of early iconic memory and readout stages of visual


processing (Asarnow & MacCrimmon, 1981) and was assessed using Version 1 of the UCLA SPAN computer program (Asarnow & Nuechterlein, 1987). Like the DS-CPT, and SPAN was presented on an IBM-PC computer with a Taxan 720 color monitor. Viewing distance was one meter, and subjects responded by pressing the appropriate button on a Gravis joystick. Subjects were told that letters would be flashed don the screen and that either the letter Tor Fwould be in each array. Either 2 or 11 nontarget letters randomly selected from the other 24 letters of the alphabet were placed in the array. Letters were presented on the screen for 80 ms. Subjects received 20 practice trials to become familiar with the procedure. During the test, each array size was presented in blocks of 16 trials; an equal number of T~ and Fs appeared within each block. Four blocks of each size array were administered. Results from the larger array were used because both normal control subjects and subjects with schizophrenia score near the ceiling on the smaller array.

Subjects completed two versions of the DSDT: a short series, comprising seven nondistractor lists of six digits interspersed with seven distractor lists of five digits, followed by a long series, comprising seven nondistractor lists of seven to eight digits interspersed with seven lists of six digits (Oltmanns & Neale, 1975). An audiotaped female voice read the target numbers and a male voice read the distractor numbers. The tape recorder was shut off after each list, and subjects were instructed to write down in order as many numbers as they could remember. Previous research showed that overall hit rate was significantly associated with psychosocial skill learning (Bowen et al., 1989); it therefore was included in the current study.

Ability to recognize and recall word lists was measured from completion of the RAVLT (Rey, 1964). Subjects were instructed to listen to a list of 15 common words read by the examiner. Subjects were to repeat aloud as many of the words as they could remember, in any order, when the examiner finished the list. The procedure was repeated two more times. The recall score equaled the total number of correctly identified words for the three trials. After a 15- minute interference task (the SPAN), subjects were read a paragraph and instructed to tap on the tabletop immediately after hearing words from the paragraph that were in the original stimulus list. The number of correctly identified words represented the recognition score on this test.

Deficits in concept formation and cognitive flexibility were assessed using a computerized version of the WCST (Heaton, 1981) developed by Wang Laboratories. The computerized version of the WCST is comparable to the card version for this population (Hellman, Green, Kern, & Christenson, 1992). During this task, subjects were instructed to match a series of stimuli to four key cards. Cards can be matched according to one of three rules or categories: color, number, or form. The only feedback the examiner provided was whether each match was correct or incorrect. The experimenter changed the rule without informing the subject after the patient matched 10 consecutive cards. Number of perserverative errors (i.e., continuing to match items to criteria that were no longer correct) has been of central interest in describing cognitive processes in previous schizophrenia research and was reported here.

Symptom measures. Subjects were also administered the expanded version

10 CORRIGAN ET AL.

of the Brief Psychiatric Rating Scale (BPRS; 24 items) to measure the effects of symptoms on skill learning (Lukoff, Nuechterlein, & Ventura, 1986). Four raters who conducted BPRS interviews had been trained previously to a minimum Intraclass Correlation (ICC [1,1]; Shrout & Fleiss, 1979) of 0.80 based on consensus ratings of the Diagnosis and Psychopathology Unit of the UCLA Clinical Research Center. Two summary scores, identified in a factor analysis by Overall, HoIlister, and Pichot (1967), were included: a Thinking Distur- bance Factor that included conceptual disorganization, hallucinations, and unusual thought content and a Withdrawal/Retardation Factor that included blunted affect, emotional withdrawal, and motor retardation.

Procedure Patients were recruited and informed as to the purposes of the study. Total

testing for those who agreed to participate required six to eight hours per patient and was completed over several individual sessions within a two-week period. Subjects received candy and soft drinks for their participation unless medically contraindicated (e.g., current diagnosis of obesity or diabetes). No subjects were excluded from the study for medical reasons.

Data Analysis

Pearson Product Moment Correlations were determined to investigate the relationships between skill learning, psychiatric symptoms, and information processing. A multiple regression was conducted, with measures of information processing and symptomatology as independent variables and skill learning as the dependent variable. Multiple regression was completed using BMDP program 2R (Dixon & Jennrich, 1988).

Results Interrater reliabilities for responses to the Medication Management Test were

high: Instructions, r(28) = 0.96; Videotaped Vignettes, r(28) = 0.95; and Role Play, r(20) = 0.92. The three skills comprising MMT scores were significantly intercorrelated (0.47 to 0.66) and therefore were summed to produce an overall MMT score for this analysis.

Correlations Between Skill Learning and Information Processing Measures

Correlations between the information-processing variables and the MMT are summarized in the top row of Table 1.1 Underlined coefficients in the Table met the Bonferroni Criterion for significance. Bonferroni Criteria were determined for four blocks of correlations: MMT by information processing variables, MMT by BPRS factors, the matrix of information-processing correlations, and information processing by BPRS factors. Significant correlations were found between the MMT and the RAVLT recall score, DSDT, and DS-CPT.

z All variables were normally distributed. Correlations were one-tailed tests.

COGNITIVE DYSFUNCTIONS AND PSYCHOSOCIAL SKILL LEARNING I 1

Only the correlation between RAVLT recall and the MMT met the Bonferroni significance level (p < .008). No significant relationships were found between the MMT and the WCST.

A simultaneous multiple regression was completed to determine the total MMT variance attributed to the information-processing variables in Table 1. Three of the six independent variables- RAVLT recall, A' from the DS-CPT, and DSDT-were selected for the analysis because the sample had only 30 subjects. These variables were included because they yielded the largest correlations with MMT. The unique variance and tolerance of each of these variables are summarized in Table 2. Tolerance for each variable was at accept- able levels. The greatest MMT variance was accounted for by RAVLT recall. The overall Multiple R was 0.66 and accounted for 44°70 of MMT variance.

Correlations Between Skill Learning and Psychiatric Symptoms The Pearson Product Moment Correlations between the MMT score and

factors on the BPRS are also summarized in Table 1. Thinking Disturbance was not significantly related to the MMT. A nonsignificant trend (p < .10) was found between Withdrawal/Retardation on the BPRS and the MMT.

TABLE 1 PEARSON PRODUCT MOMENT CORRELATIONS BETWEEN VARIABLES MEASURING INFORMATION

PROCESSING, PSYCHIATRIC SYMPTOMS, AND PSYCHOSOCIAL SKILL LEARNING

DS-CPT RAVLT RAVLT WCST Think Withdrw/ A' SPAN recall recogn DSDT PE Disturb Retard

MMT overall score .43* .19 .59*** .28 .48** - . 1 4 .01 - .33 Vigilance

DS-CPT A' .26 .59*** .07 .27 - .18 - . 04 - .35 Iconic memory

SPAN matrix 12 .07 .01 .38* .12 - .25 - .07 Verbal memory

RAVLT recall .34 .34 - .23 - 44* - .36 RAVLT recognition .06 - .18 - . 26 - .21

Serial recall DSDT total correct .00 .07 .00

Cognitive flexibility WCST PEs - .27 .30

MMT: Medication Management Test; DS-CPT: Degraded-Stimulus Continuous Performance Test; SPAN: Span of Apprehension; RAVLT: Rey Auditory Verbal Learning Test; DSDT: Digit Span Distractor Test; WCST: Wisconsin Card Sorting Test; PEs: Perseverative Errors; Think Disturb: Thinking Disturbance factor on the Brief Psychiatric Rating Scale; Withdrw/Retard: Withdrawal/Retardation factor on the Brief Psychiatric Rating Scale. * p <: .01 ** p < .01 *** p < .001 Underlined coefficients met Bonferroni Criterion for significance.

12 CORRIGAN ET AL.

TABLE 2 THE AMOUNT OF UNIQUE VARIANCE, TOLERANCE, AND R 2

FOR THE TWO REGRESSION ANALYSES

Medication Management Test

Predictor Unique variance Tolerance

Analysis 1 RAVLT recall .37 .61 DS-CPT A' .00 .64 DSDT total correct .07 .88

R ~ = .44 Analysis 2

RAVLT recall .32 .75 DSDT total correct .11 .87 Withdrawal/Retardation .03 .85

R 2 --- .46

Note. DS-CPT: Degraded-Stimulus Continuous Performance Test; RAVLT: Rey Auditory Verbal Learning Test; DSDT: Digit Span Distractor Test

A second simultaneous multiple regression was completed to determine the total MMT variance attributed to information processing and symptom variables and is summarized in Table 2. Independent variables in this analysis included RAVLT recall, DSDT total correct, and the Withdrawal/Retardation factor. Once again, RAVLT recall accounted for the majority of MMT variance in this analysis. The Multiple R was 0.67, accounting for 45% of MMT variance.

Discussion The purpose of this study was to identify individual differences that might

affect psychosocial skill learning strategies; in particular, the effects of information processes and psychiatric symptoms were examined. Results showed medication self-management skill learning in patients with schizophrenia to be significantly correlated with measures of short-term recall and visual vigilance. Only one of these variables- recall memory-met the Bonferroni Cri- terion for significance with skill learning. Interestingly, recognition memory was not found to be associated with skill learning. This negative finding, however, is difficult to interpret because many of the subjects in this study scored near the ceiling on the recognition task.

Surprisingly, skill learning was not significantly associated with conceptual flexibility as measured by the WCST, one might expect psyehosocial functioning to be associated with more complex information processing functions. This finding replicates earlier results by Kern et al. (1992) and is not likely due to the power of the statistical test. Effect sizes of this and Kern et al.'s correlation (0.28 and 0.27, respectively) are both small according to Cohen's (1977) criteria. The absence of correlation makes more sense after some consideration of the

COGN/TIVE DYSFUNCTIONS AND PSYCHOSOCIAL SKILL LEARNING 13

nature of the MMT, namely, the measure represents a patient's ability to learn skills, not to be able to use these skills in what Peter Trower (1982) would call a generative manner in the real world. Future research may find significant relationships between conceptual flexibility and more generative social skills, such as interpersonal problem solving.

Significant relationships were not found between thinking disturbance and the MMT. The lack of correlation between psychotic symptoms and skill learning is somewhat puzzling at first glance. One would think that highly thought-disordered patients would have more difficulty learning targeted skills. These findings suggest, however, that patients are able to learn psychosocial skills irrespective of the severity of their psychotic symptoms. A nonsignificant trend between skill learning and Withdrawal/Retardation on the BPRS was consistent with results from previous studies; i.e., patients who exhibit negative symptoms do worse in social learning tasks (Bellack et al., 1989).

Findings from this study have implications for the psychosocial rehabilitation of patients with schizophrenia both in terms of assessment and intervention. The memory deficits of patients with schizophrenia may hamper their ability to learn psychosocial skills. This findings suggests that clinicians might employ simple measures of verbal memory to assess a patient's capacity to benefit from skills training modules. Previous investigations of rehabilitation with patients with schizophrenia have attempted to improve cognitive dysfunc- tion by utilizing repeated practice or operant strategies to ameliorate "attentional" deficits (Adams, Branfly, Malatesta, & Turkat, 1981; Green, 1993; Karras, 1962, 1968; Meiselman, 1973; Rosenbaum, MacKavey, & Grisell, 1957; Wagner, 1968). Results from this study suggest that skill learning may be better amelio- rated when rehabilitative efforts that address deficits in short-term recall memory are added to the skills training program. The combination of rehabilitation efforts may improve both the limiting factor (i.e., verbal memory) and the targeted skill (e.g., medication management).

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RECEIVED: March 6, 1993 ACCEPTED: July 21, 1993

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Learning medication self-management skills in schizophrenia: Relationships with cognitive deficits and psychiatric symptoms