Optimizing Cognitive Behavioral Social Skills Training with Executive Function Training for Older Adults with Schizophrenia

ABSTRACT By the year 2050, the US population over age 65 will double and the population over age 85 will increase 5-fold. A large and increasing number of older people with schizophrenia will need more effective services. Older adults with schizophrenia are at risk for cognitive and functional decline leading to premature institutionalization. Over the past two decades, we developed Cognitive Behavioral Social Skills Training (CBSST) and established its efficacy for preventing functional decline in people with schizophrenia. In longitudinal studies, older participants with schizophrenia receiving CBSST did not improve significantly in functioning but did remain stable over 1-2 years, whereas older participants in treatment as usual and supportive contact (SC) experienced decline in functioning. CBSST is now recommended by SAMSHA as an evidence-based psychosocial intervention to prevent functional decline in middle-age to older adults with schizophrenia. Our prior work focused primarily on middle-aged adults, but our recent pilot data also showed that CBSST can prevent decline in functioning in adults with schizophrenia aged 60 or above (mean age (SD) = 65.3 (5.3)). In this late-life schizophrenia clinical trial, we also observed: (1) patients who showed larger improvement in CBSST Skills Learning showed significant improvement, not just stability, in functioning at 1-year follow-up; and (2) CBSST Skills Learning was predicted by baseline executive function. These findings suggest that CBSST Skills Learning is an important mechanism of change in functioning in CBSST and that boosting executive function could boost CBSST Skills Learning, which could improve rather than only stabilize functioning. Our group has also developed an Executive Function Training program that improves executive function but has only modest impact on functioning in mid-life adults with schizophrenia. Thus, given (1) the extensive evidence that CBSST maintains but does not improve functioning in mid- and late-life adults with schizophrenia; (2) Executive Function Training improves executive function but has limited effect on functioning; and (3) CBSST Skills Learning is associated with executive function, we propose a two-site R61/R33 to test among adults with late-life schizophrenia whether combining Executive Function Training with CBSST (E-CBSST) will result in better CBSST Skills Learning, and in turn, improve rather than only maintain functioning. If successful, we will test E-CBSST in a larger confirmatory trial and if successful E-CBSST would be the first psychosocial intervention to lead to such improvement in late-life schizophrenia. There is no doubt that stronger effective treatments for functional disability in late-life individuals living with schizophrenia would have a profound effect on patients, family members, society and the economy.