Aota - Guideline Mental Health

T h e A O TA P r a c t i c e G u i d e l i n e s S e r i e s
Occupational Therapy Practice Guidelines for
Adults Living With

Serious Mental Illness
i
T h e A O TA P r a c t i c e G u i d e l i n e s S e r i e s
Occupational Therapy Practice Guidelines for
Adults Living With

Susan Noyes, PhD, OTR/L

Associate Professor
Master of Occupational Therapy (MOT)
Program
University of Southern Maine, Lewiston
Elizabeth Griffin Lannigan, PhD,

OTR/L, FAOTA
Adjunct Faculty
Department of Occupational Therapy
College of Health and Human Services
University of New Hampshire, Durham
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AOTA Vision 2025
Occupational therapy maximizes health, well-being, and quality of life for all people, populations, and communities
through effective solutions that facilitate participation in everyday living.
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Reference citation: Noyes, S., & Lannigan, E. G. (2019). Occupational therapy practice guidelines for adults living
with serious mental illness. Bethesda, MD: AOTA Press.
Contents
Acknowledgments��vii
About This Publication��viii
Executive Summary�� x
Abbreviations and Acronyms Used in This Publication��xvi
Chapter 1. Overview of Serious Mental Illness�� 1

Serious Mental Illness�� 1
Mental Disorders Considered SMI�� 2
Schizophrenia Spectrum Disorders�� 2
Bipolar Disorders�� 3
Major Depressive Disorders�� 3
Co-occurrence and Other Considerations�� 3
Occupational Therapy Perspectives for Individuals Living With SMI�� 5
Key Components of the Recovery Perspective�� 6
Occupational Therapy’s Link to Recovery Perspectives�� 7
Chapter 2. Systematic Review Methodology and Overview of Findings�� 8

Background�� 8
Evidence Evaluation�� 8
Review Methodology�� 9
Search Terms�� 9
Databases Used�� 9
Inclusion and Exclusion Criteria�� 9
Overview of Search Results�� 10
Process�� 10
Strength of Evidence�� 11
Benefits and Harms�� 12
Clinical Reasoning�� 12
Chapter 3. Evidence for Interventions to Promote ADLs and IADLs, Rest and Sleep, Leisure,
and Social Participation�� 13
Interventions�� 13
Occupation-Based Interventions�� 14
Psychoeducation Interventions�� 14
Skills Training Interventions�� 15
Cognition-Based Interventions�� 15
Technology-Supported Interventions�� 16
Moving Research Into Practice�� 16
Chapter 4. Evidence for Interventions to Support Employment and Education�� 17

Individual Placement and Support Interventions�� 18
Cognitive Interventions�� 20
iii
OC C U P A T ION A L T HE R AP Y P R A CT I C E G UI DEL I N ES F O R A D U L TS L I VI N G W I TH SERI O U S M EN TA L I L L NESS
Supported Education Interventions�� 21

Chapter 5. Evidence for Interventions to Promote Health and Wellness�� 22

Physical Health Interventions�� 23
Relaxation Interventions�� 24
Exercise Interventions�� 24
Weight Loss Interventions�� 25
Chapter 6. Evidence for Interventions to Support Early Intervention for Adolescents and
Young Adults Living With SMI�� 29
Cognitive Remediation Interventions�� 30
Cognitive–Behavioral Therapy�� 30
Clinical High Risk or First-Episode Psychosis�� 31
Depression�� 31
Supported Employment/Supported Education�� 31
Family Psychoeducation Interventions�� 32
Chapter 7. Evidence for Interventions to Reduce Internalized Stigma�� 34

Psychoeducation Interventions�� 35
Cognitive–Behavioral Therapy Interventions�� 36
Social Skills Training Interventions�� 36
Narrative Enhancement and Cognitive Therapy Interventions�� 36
Group Discussion Interventions�� 36
Vocational Rehabilitation Interventions�� 36
Chapter 8. Implications of the Evidence for Occupational Therapy Practice, Education, and
Research�� 38
Implications for Occupational Therapy Practice�� 38
Interventions to Promote ADLs and IADLs, Rest and Sleep, Leisure, and Social
Participation�� 38
Interventions to Support Employment and Education�� 38
Interventions to Promote Health and Wellness�� 38
Interventions to Support Early Intervention�� 39
Interventions to Reduce Internalized Stigma�� 39
General Implications for Practice�� 39
Implications for Occupational Therapy Education�� 39
Implications for Occupational Therapy Research�� 40
Conclusion�� 40
Chapter 9. Clinical Recommendations for Interventions for Adults Living With Serious
Mental Illness�� 41
Chapter 10. Case Studies�� 44
References�� 51
Appendix
Appendix A. Evidence and Risk-of-Bias Tables��A1
iv
Contents
Boxes and Tables

Box 10.1. Case Study 1. Pete—Early Intervention, Employment, and Internalized Stigma�� 44
Box 10.2. Case Study 2. Alida—ADLs, IADLs, and Leisure Management�� 46
Box 10.3. Case Study 3. Ed—Social Participation and Health and Wellness�� 49
Table 2.1. Levels of Evidence�� 9

Table 2.2. Search Terms for the Systematic Reviews of Occupational Therapy
Interventions for Adults Living With SMI�� 10
Table 2.3. Number of Articles Included in the Systematic Reviews, by Topic and Level of
Evidence�� 11
Table 2.4. Strength of Evidence�� 11
Table 3.1. Levels of Evidence for Interventions to Promote ADLs and IADLs, Rest and
Sleep, Leisure, and Social Participation�� 13
Table 4.1. Levels of Evidence for Interventions to Support Employment and Education�� 18
Table 5.1. Levels of Evidence for Interventions to Promote Health and Wellness�� 22
Table 5.2. Levels of Evidence for Health and Wellness Interventions, by Theme�� 23
Table 6.1. Levels of Evidence for Interventions to Support Early Intervention for
Adolescents and Young Adults Living With SMI�� 29
Table 6.2. Levels of Evidence for Interventions to Support Early Intervention for
Adolescents and Young Adults Living With SMI, by Theme�� 30
Table 7.1. Levels of Evidence for Interventions to Reduce Internalized Stigma�� 34

Table 7.2. Levels of Evidence for Internalized Stigma Interventions, by Theme�� 35
Table 9.1. Clinical Recommendations for Occupational Therapy Interventions for Adults
Living With SMI�� 42
Table A.1. Evidence Table for the Systematic Review of Interventions to Promote ADLs
and IADLs, Rest and Sleep, Leisure, and Social Participation for Adults Living With
SMI��A2
Table A.2. Risk-of-Bias Analysis for Intervention Studies Included in the Systematic
Review of Interventions to Promote ADLs and IADLs, Rest and Sleep, Leisure, and
Social Participation for Adults Living With SMI��A27
Table A.3. Risk-of-Bias Analysis for Systematic Reviews Included in the Systematic
Table A.4. Evidence Table for the Systematic Review of Interventions to Support
Employment and Education for Adults Living With SMI��A31
Review of Interventions to Support Employment and Education for Adults Living
With SMI��A67
With SMI��A70
Table A.7. Evidence Table for the Systematic Review of Interventions to Promote
Health and Wellness for Adults Living With SMI��A71
Review of Interventions to Promote Health and Wellness for Adults Living
With SMI�� A104
Review of Interventions to Promote Health and Wellness for Adults Living
With SMI��A108
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Table A.10. Evidence Table for the Systematic Review of Early Intervention for
Adolescents and Young Adults Living With SMI�� A110
Review of Early Intervention for Adolescents and Young Adults Living With SMI�� A122
Review of Early Intervention for Adolescents and Young Adults Living With SMI�� A124
Table A.13. Evidence Table for the Systematic Review of Interventions to Reduce
Internalized Stigma for Adults Living With SMI�� A125
Review of Interventions to Reduce Internalized Stigma for Adults Living With SMI�� A136
Review of Interventions to Reduce Internalized Stigma for Adults Living With SMI�� A138
vi
Acknowledgments
The series editor for this Practice Guideline is • arson Lund, MOT, OTR
C
Deborah Lieberman, MHSA, OTR/L, • Barbara Nadler, MS
FAOTA • Sean Roush, OTD, OTR/L, QMHP
Director, Evidence-Based Practice • Helena Sokolow, MOT, OTR/L
Staff Liaison to the Commission on Practice • Megan Steuter, MOT, OTR/L
American Occupational Therapy Association • Margaret (Peggy) Swarbrick, PhD,
Bethesda, MD FAOTA
• Mikkaela Toenies, MOT, OTR/L
The issue editor for this Practice Guideline is
• Mirtha M. Whaley, PhD, MPH, OTR/L
Elizabeth G. Hunter, PhD, OTR/L
Assistant Professor, Graduate Center for The authors acknowledge and thank the fol-
Gerontology lowing individuals for their participation in
College of Public Health the content review and development of this
University of Kentucky publication:
Lexington • Catana Brown, PhD, OTR/L, FAOTA
• Mariana D’Amico, EdD, OTR/L, BCP,
The research methodologists for this Practice FAOTA
Guideline are • Donna T. Downing, MS, OTR/L
Marian Arbesman, PhD, OTR/L, FAOTA • Jennifer A. Gardner, OTD, OTR
President, ArbesIdeas, Inc. • Janice D. Hinds, MS, OTR/L,
Consultant, AOTA Evidence-Based Practice BCMH
Project • Lynn Jaffe, ScD, OTR/L, FAOTA
Clinical Assistant Professor, Department of • Lisa Mahaffey, PhD, OTR, FAOTA
Rehabilitation Science • Randy P. McCombie, PhD, OTR/L
State University of New York at Buffalo • Heather Parsons, MSOT (AOTA Policy
Elizabeth G. Hunter, PhD, OTR/L representative)
Assistant Professor, Graduate Center for • Deborah B. Pitts, PhD, OTR/L, BCMH,
Gerontology CPRP
College of Public Health • Hillary Richardson, MOT, OTR/L
University of Kentucky (AOTA Program Manager)
Lexington • Sean Roush, OTD, OTR/L, QMHP
• Helena Sokolow, MOT, OTR/L
The authors acknowledge the following indi- • Margaret (Peggy) Swarbrick, PhD,
viduals for their contributions to the evidence- FAOTA
based systematic review:
• Shaik Ali, MOT, OTR The authors acknowledge and thank the fol-
• Catana Brown, PhD, OTR/L, FAOTA lowing individual for her participation in the
• Mariana D’Amico, EdD, OTR/L, BCP, content review and development of this publi-
FAOTA cation from the consumer perspective:
• Donna T. Downing, MS, OTR/L • Rita Cronise, MS, ALWF
• Melissa Engelhardt, MOT Note. The authors of this Practice Guideline
• Lydia C. Geiszler, MOT, OTR/L have signed a Conflict of Interest statement
• Lynn Jaffe, ScD, OTR/L, FAOTA indicating that they have no conflicts that
• Kelsie J. Lewis, MOT, OTR/L would bear on this work.
vii
About This Publication
Practice guidelines have been widely developed in response to the health care reform movement
in the United States. Such guidelines can be useful tools for improving the quality of health
care, enhancing consumer satisfaction, promoting appropriate use of services, and reduc-
ing costs. The American Occupational Therapy Association (AOTA), which represents nearly
213,000 occupational therapists, occupational therapy assistants, and students of occupational
therapy, is committed to providing information to support decision making that promotes
high-quality occupational therapy services within the health care system that are affordable
and accessible to all.
Using an evidence-based perspective and key concepts from the third edition of the
Occupational Therapy Practice Framework: Domain and Process (AOTA, 2014), this Practice
Guideline provides an overview of the occupational therapy process for individuals living with
serious mental illness (SMI). The systematic review process was initiated to address five focused
occupational therapy intervention questions and was not intended to incorporate the complex-
ity of personal, social, cultural, societal, and environmental factors that influence individual
participation in society for this population. Occupational therapy practice can, however, sig-
nificantly contribute to the change needed at societal and organizational levels, as well as at the
level of the individual client. This Practice Guideline discusses interventions that occur within
the boundaries of the occupational therapy domain and process. Although this guideline does
not discuss all possible methods of care, some specific methods are recommended. Occupational
therapy practitioners must make the ultimate judgment regarding the appropriateness of a given
intervention in light of a specific person’s or group’s circumstances and needs and the evidence
available to support the intervention.
It is the intention of AOTA, through this publication, to help occupational therapists and
occupational therapy assistants, as well as the individuals who manage, reimburse, or set policy
regarding occupational therapy services, understand the contribution of occupational therapy
in providing services to individuals living with SMI. This guideline can also serve as a reference
for health care professionals, health care facility managers, education and health care regulators,
third-party payers, managed care organizations, and those who conduct research to advance
care of individuals living with SMI.
This document may be used in any of the following ways:
• To assist occupational therapists and occupational therapy assistants in providing evi-
dence-based interventions to individuals living with SMI
• To assist occupational therapists in the selection of appropriate assessments and outcome
measures to evaluate treatment outcomes and the effectiveness of interventions used with
individuals living with SMI
• To assist occupational therapists and occupational therapy assistants in communicating
about occupational therapy services to external audiences
• To assist other health care practitioners, case managers, clients, families and caregivers,
and health care facility managers in determining whether referral for occupational therapy
services is appropriate
• To assist third-party payers in determining the medical necessity for occupational therapy
services
• To assist program developers; administrators; legislators; federal, state, and local agencies;
and third-party payers in understanding the scope of occupational therapy services
viii
A bo u t Th i s Pu blication
• T o assist occupational therapy researchers in this practice area in determining outcome

measures and defining current occupational therapy practice to compare the effectiveness
of occupational therapy interventions
• To assist policy and health care benefit analysts in understanding the appropriateness of
occupational therapy services for individuals living with SMI
• To assist occupational therapy educators in designing appropriate and evidence-based cur-
ricula for providing occupational therapy services to individuals living with SMI.
Chapter 1 of this Practice Guideline provides an overview of adults living with SMI, and
Chapter 2 describes the method used to conduct the systematic reviews. Chapters 3 through 7
provide a brief overview of each focused question and the results of systematic reviews of evi-
dence from the scientific literature regarding best practices in occupational therapy intervention
for adults living with SMI. Implications of the evidence for practice, education, and research are
reviewed in Chapter 8, and Chapter 9 summarizes the findings into clinical recommendations
for occupational therapy practice. Chapter 10 offers case studies providing examples of how to
integrate and apply the findings in clinical practice. Evidence tables and risk-of-bias tables for all
articles included in the reviews are found in Appendix A.
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Executive Summary
Background
One in 6 Americans live with some form of mental illness, according to the National Institute of
Mental Health (NIMH). Among this group, which includes any person with an NIMH-identified
mental, behavioral, or emotional disorder, is a subset of people who live with serious mental illness
(SMI), in which the disorder impairs functioning and interferes with one or more major life activities.
An estimated 44.7 million people, or 18.3% of the adult population, live with mental illness in the
United States, and an estimated 10.4 million people, or 4.2% of the adult population, live with SMI.
Identifying SMI involves three factors: (1) diagnosis, (2) functional impairment, and (3) dura-
tion of illness. NIMH distinguishes people living with SMI as having, during the past year, a diag-
nosable mental, behavior, or emotional disorder that causes functional impairment and limits or
impairs one or more major life activities. The most common identified conditions are major depres-
sion, schizophrenia, bipolar disorder, and other mental disorders that cause serious impairment.
People living with SMI can face certain challenges at higher rates than the general population,
including unemployment (38% employed, vs. 62% of the general population), homelessness
(accounting for 25% of the population in shelters), and arrest. Recent research has estimated
that 350,000 people living with SMI are imprisoned in the United States. In the juvenile justice
system, 70% of the population have one or more mental health conditions, with 25% experienc-
ing these disorders at a severe level.
Because of their training in psychosocial and mental health interventions and their involve-
ment in providing occupation-based interventions, occupational therapy practitioners can play
an important role in helping clients living with SMI to participate in everyday life. By becoming
involved in this way, practitioners may lessen or avert some of the negative effects that SMI can
have on clients and their families.
Practice Guidelines Overview

Purpose
The American Occupational Therapy Association (AOTA) instituted its Evidence-Based Practice
Project to review the existing literature that might inform best practices for occupational therapy
and spur discussion about education and future research needed in the field. Ultimately, practice
guidelines are developed with the goals of improving health care quality, increasing patient satis-
faction, promoting appropriate services, and reducing health care costs.
Selecting appropriate interventions to use with occupational therapy clients requires integrat-
ing information from three sources: (1) clinical experience and reasoning, (2) preferences of cli-
ents and their families, and (3) findings from the best available research. These guidelines, which
provide findings, should be useful to many professionals involved in providing occupational
therapy services for adults living with SMI, including occupational therapy practitioners, educa-
tors, clients, families, caregivers, third-party payers, and policymakers.
Method
This publication was developed using newly developed systematic reviews of the published
literature on the efficacy of various interventions within the scope of occupational therapy for
adults living with SMI. All studies identified in the review can be found in Appendix A of the
full Practice Guideline. The systematic reviews were published in the September/October 2018
issue of the American Journal of Occupational Therapy. These guidelines are intended to provide
x
Exec u ti ve Summary
information on the effectiveness of occupational therapy interventions to support functioning

and participation for adults living with SMI (as well as their families or other caretakers) in the
following intervention areas: (1) activities of daily living (ADLs) and instrumental activities of
daily living (IADLs), rest and sleep, leisure, and social participation; (2) employment and educa-
tion; (3) health and wellness; (4) early intervention; and (5) internalized stigma. A full list of the
databases queried and the search terms used to find studies of interventions in these areas can be
found in the “Review Methodology” section of the full guidelines (Chapter 2).
Peer-reviewed interventions presented here include Level I (systematic reviews and random-
ized controlled trials [RCTs]), Level II (non-randomized cohort), Level III (no control group),
and Level IV (experimental single-case) studies. Level V (descriptive case) studies were not
included in this review.
Evidence strength comes from the quantity and quality of studies. For each area of interven-
tion, a designation of strong evidence denotes consistent results from at least 2 well-designed
Level I RCTs, systematic reviews, or meta-analyses. Moderate evidence means consistent results
from 1 Level I study or from 2 or more lower level studies. Limited evidence means few, lower
level studies were found, with some inconsistency in the results observed. Insufficient evidence
denotes that the number and quality of studies do not allow for determining a strength rating.
Studies included in this guideline did not have any adverse events (harms) to report. Knowing
the evidence for an intervention, practitioners must use clinical knowledge, research about pos-
sible obstacles, and an understanding of the client’s needs and limitations when determining
whether to proceed with a given program.
Summary of Key Findings

Interventions Supporting ADLs and IADLs, Rest and Sleep, Leisure, and Social
Participation
Promoting performance of daily life activities lies at the heart of occupational therapy; research
in how available interventions can promote this performance among adults living with SMI
is therefore critical to this type of review. Authors of this review found 61 studies meeting the
guidelines for inclusion in this review, indicating an increase in the amount of research done
in this area since the last systematic review, published in 2011. The interventions studied fell
into five broad categories: (1) occupation-based, (2) psychoeducation, (3) skills training, (4)
cognition-based, and (5) technology-supported interventions.
Occupation-Based Interventions.
• O ccupation-based interventions showed strong evidence of improving social participa-
tion; clients using such interventions displayed increased motivation for occupational
engagement.
• Moderate evidence was found to support the use of occupation-based interventions to
support performance of ADLs and IADLs. Interventions that used individualized, client-
centered goals showed better results.
• Moderate evidence supports using occupation-based interventions to increase leisure
activities. However, participation in these activities was not sustained by the clients after
the end of the intervention period.
• Moderate evidence supports the use of exercise interventions to support sleep, because
such interventions resulted in improved sleep among patients with nonremitted major
depression disorder taking medication at varying dosage levels.
• Insufficient evidence was found to make a recommendation on animal-assisted therapy for
promoting social participation and engagement among adults with schizophrenia.
Psychoeducation Interventions.
• S trong evidence supports the use of psychoeducation programs, such as the Adherence
Therapy program and the Illness Management and Recovery program. Although the
implementation of these types of programs can vary, in 4 Level I RCTs examining these
programs, patients involved in the intervention showed significantly improved ADL and
IADL performance over patients who did not participate.
xi
• M oderate evidence from 2 Level I systematic reviews supports the use of psychoeducation
programs to improve sexual activity safety among participants.
• Psychoeducation for adults living with refractive bipolar disorders and schizophrenia spec-
trum disorders showed mixed evidence for its effectiveness. The evidence indicates that the
effectiveness of certain interventions in this area is dependent on the individual diagnosis.
• A study of more individualized methods delivered as part of a collaborative care program
for patients with bipolar disorder showed some evidence of improvements in functioning
and autonomy.
Skills Training Interventions.

• M ixed evidence was found for the effectiveness of skills training interventions across 5
Level I RCTs.
• Strong evidence was found to support the Helping Older People Experience Success
(HOPES) program, a yearlong weekly training program, where an RCT of older adult
patients found improvements in community living skills, health care use, social function-
ing, and negative symptoms.
Cognition-Based Interventions.
• S trong evidence was found from 5 RCTs for use of cognition-based interventions, com-
bined with aspects of social interaction or skills training, to improve social participation.
Researchers found improvements in social interaction, relationships, and quality of life
(QOL) above those improvements resulting from social skills training alone. For example,
the Social Cognition and Interaction Training (SCIT) program, when combined with
social mentoring, provided improved social engagement outcomes for participants in 2
studies.
• A Level I systematic review of interventions including cognitive–behavioral therapy (CBT),
social skills training, exercise, alternative therapies, and art therapy provided moderate evi-
dence for improved social functioning for participants with depression but mixed evidence
for participants with schizophrenia.
• Across 21 Level I studies (20 RCTs, 1 systematic review), reviewers found insufficient evi-
dence for the use of cognition-based interventions to improve ADLs and IADLs in adults
living with SMI.
• Three Level I RCTs and 1 Level II study showed significant improvements in sleep outcomes
among people who received interventions in this area, including mindfulness training, relax-
ation breathing, and CBT, providing strong evidence for this type of intervention in improving
or maintaining rest and sleep performance.
Technology-Supported Interventions.
• I nsufficient evidence has been found to date to support the use of technology-supported
interventions to improve IADL performance.
Interventions to Support Employment and Education

Employment and education can be a considerable challenge to successful daily engagement for
adults living with SMI. In addition to the role of meaningful employment or education in the
recovery process, engagement in these activities includes benefits such as potential increases
in financial stability, social interactions, self-esteem, and community integration. This area
of intervention is heavily studied, and 57 studies met the criteria for inclusion in this review.
Interventions to help adults living with SMI to engage in meaningful education and employment
were categorized into three areas: (1) the individual placement and support (IPS) model, (2) cog-
nitive interventions, and (3) supported education programs.
• Key elements of the IPS model for employment include prioritizing clients’ choices and
preferences throughout the process as well as a rapid job search, unlimited individualized
support, and integrating the client’s vocational and mental health teams. It was developed
as an alternative to traditional vocational rehabilitation (TVR) and is often tested against
it. Four systematic reviews found increased levels of competitive employment when IPS
interventions were used.
xii
• E ight of 11 RCTs studied showed improved vocational outcomes from clients using IPS
over those using TVR. Outcomes included double the rates of competitive employment
and job tenure, as well as more hours worked, higher total income, and improved QOL.
• Cognitive interventions have been a prime area for research since a 1996 study demon-
strated the impact of cognitive deficits on the functioning of patients with schizophrenia.
Since then, cognitive remediation treatments (CRTs) have been a prime focus of interven-
tions for this group. Eighteen studies in this area were included in this review: 1 Level I
meta-analysis, 14 Level I RCTs, 2 Level II studies, and 1 Level III study. Overall, they
provide strong evidence for the benefits of cognitive interventions to improve employment
outcomes in these clients.
• Cognitive interventions studied included combination programs, such as neurocognitive
enhancement therapy combined with a vocational program or the Thinking Skills for
Work program combined with an enhanced supported employment program. Participants
in these studies showed improved vocational outcomes in employment, wages, and hours
worked over vocational interventions used alone.
• Five RCTs of CRTs showed cognition measures to be an important predictor for employ-
ment and positive job outcomes.
• An intervention in which participants did virtual-reality job interviews found improved
cognition in participants and increased job offers.
• Only 2 studies (both Level I) met the criteria for supported education interventions. They
provide moderate evidence for the effectiveness of these interventions, with participants
showing improved academic skills and functioning.
Interventions to Promote Health and Wellness

The significant differences in health outcomes for largely treatable conditions between adults
requiring mental health services and the general population has led to this area’s identification
as one in which occupational therapy interventions may be of considerable help. Adults living
with SMI can expect to live, on average, 25 years less than the general population, because they
are less likely to engage in healthy lifestyle behaviors and they have higher rates of cardiovascu-
lar disease, infectious disease, diabetes, respiratory disease, and cancer. Reviewers identified 85
studies of interventions in this area and included only Level I studies because of the quantity of
research. Studies were placed into four categories: (1) physical health, (2) relaxation, (3) exer-
cise, and (4) weight loss.
• Six systematic reviews and 9 RCTs provide strong evidence for the value of physical health
interventions to improve the health of clients with SMI. Many of the studies in this area
used a version of the Stanford Chronic Disease Self-Management Program (SCDSMP),
whereas others used peer support and coaching. Positive outcomes found from these types
of programs included increased visits to primary care providers, positive attitudes toward
self-management, increases in self-reported healthy lifestyle behaviors, reduced drug use
and substance dependence, improved medication adherence, reduced hospitalization, and
increased participation in health screenings and immunizations.
• Strong evidence was found to support weight loss interventions. The interventions
included in this review included a range of components, such as exercise, educational ses-
sions, motivational interviewing, mentor programs, behavior therapy, and diet changes.
The most effective interventions focused on specific behavior changes, such as dietary rec-
ommendations, and included content on both nutrition and physical activity, incorporated
into both group and individual sessions. Weight loss in these interventions appeared com-
parable with weight loss in similar interventions delivered in the general population.
• Four systematic reviews and 12 RCTs provide strong evidence for the value of relaxation
interventions, such as yoga, progressive muscle relaxation, meditation, and tai chi.
• Yoga was found to be effective in reducing psychiatric symptoms in patients with schizo-
phrenia and anxiety, and it helped improve sleep, postural stability, and QOL in clients
living with SMI. Mixed evidence was found for the effectiveness of yoga in improving
depression, although 1 systematic review showed improvements in depression among cli-
ents with schizophrenia who participated in a yoga intervention.
xiii
• M editation had a statistically significant positive effect on depression and sleep among
participants living with depression, but no more so than behavioral activation.
• Strong evidence was found in 2 RCTs for progressive muscle relaxation to reduce anxi-
ety among participants living with SMI. The intervention also showed some evidence of
improving subjective well-being.
• Tai chi was not found to reduce depression symptoms.
• Exercise interventions were the most studied in this area, with 25 RCTs and 9 systematic
reviews providing strong evidence for the effectiveness of these interventions. Most of
these programs focused on cardiovascular exercise, walking, or participation in recre-
ational activities. Positive outcomes found included improved memory, improved sleep,
and reduced psychiatric symptoms.
• Studies of exercise interventions on patients with depression showed mixed results in
improving depressive symptoms.
• Many studies in this area did not examine fitness levels as an outcome, and some did not
find differences between intervention and control groups on these measures.
Early Intervention
Many SMIs emerge as people transition from childhood to young adulthood. Early detection
and early intervention might reduce or delay the impact of SMI. It also could help improve out-
comes for many adults living with SMI by reducing the risk of death or suicide and by prevent-
ing lifelong disability issues such as unemployment, incomplete education, social isolation, and
symptoms that interfere with daily living. Reviewers identified 30 studies of interventions that
target young adults who have recently experienced their first episode of psychosis. They include
interventions in the areas of (1) cognitive remediation (CR), (2) CBT, (3) supported employment/
supported education (SE/SE), and (4) family psychoeducation (FPE).
• Strong evidence was found for the effectiveness of SE/SE programs for youth at high risk
for or who have had a first episode of psychosis. These interventions showed positive out-
comes in both education and employment. Limited evidence was found for the effective-
ness of vocational assistance, with a decline in outcomes noted in the 6-month period after
the intervention ended.
• CR interventions involve behavioral training in practice drills or training in compensa-
tory strategies to improve cognitive functioning in areas such as attention, memory,
executive functioning, social cognition, and metacognition. This training is done
through computer programs or manual exercises facilitated by a practitioner. Available
research provides strong evidence for the benefits of CR in early intervention for psy-
chosis, with clients showing improvements in cognition, self-esteem, and social occupa-
tion across 6 Level I studies at their endpoints. However, after 3 months the clients did
not show improved or maintained functional gains, leaving doubt about the duration of
the effects.
• Nine Level I studies were found examining the impact of CBT interventions—which consist
of structured education sessions focusing on cognitive restructuring and problem-solving—
on youth with high risk for psychosis, first-episode psychosis, or depression. The effects
of some of these interventions included gains in or maintenance of cognitive functioning,
reduced relapse rates, and a longer time between relapses (relapses themselves being linked
with lower cognitive functioning), but those gains were not sustained over the long term.
Additionally, 3 of these RCTs found no differences between CBT and control groups. Three
Level I RCTs found mixed evidence as to the effectiveness of CBT in youths with depression.
• FPE involves training in communication enhancement and problem-solving skills for fam-
ily members. Moderate evidence was found for the ability of these interventions to reduce
symptoms and to improve functioning in clients with SMI.
Interventions to Reduce Internalized Stigma

A growing number of people living with SMI develop elevated internalized stigma, meaning
that they adopt the negative stigmatizing beliefs that exist in society, such as the idea that they
are dangerous or incompetent. This elevated stigma can affect self-esteem, relationships, and
xiv
functional outcomes, reducing QOL and sometimes leading to self-fulfilling prophecies of fail-
ure. Reviewers identified 20 studies of interventions in this area. Although research in this area is
limited at present, occupational therapy practitioners can play a role in helping clients avoid the
pitfalls associated with internalized stigma through a combination of education, skill-building,
and increased community participation. Interventions in this area include (1) psychoeducation,
(2) CBT, (3) social skills training (SST), (4) Narrative Enhancement and Cognitive Therapy
(NECT), (5) group discussion, and (6) vocational rehabilitation.
• Psychoeducation interventions involved one of two approaches: either targeting the stig-
matizing beliefs held by the individual or building self-esteem and empowerment, the latter
of which has been increasingly studied by experts in the field of stigma research. Moderate
evidence of effectiveness was found for psychoeducation interventions to reduce the nega-
tive impact of self-stigma and to improve QOL.
• Limited evidence was found for the use of CBT to reduce self-stigma.
• Single studies provided some evidence for the effectiveness of interventions including SST
at reducing stigma, but the positive effects were not necessarily sustained after the inter-
vention ended.
• Two studies of NECT interventions provide mixed evidence of effectiveness: A Level II
study showed improved QOL, but a Level I study showed no difference between control
and intervention groups.
• Studies of group discussion interventions had mixed results, but they provided moderate
evidence for the effectiveness of this type of intervention in reducing self-stigma.
• Limited evidence from 1 Level II study was found to support the effectiveness of voca-
tional rehabilitation interventions to reduce stigma and emotional discomfort.
Implications for Practice, Education, and Research

A complete review of the implications for practice, as well as the full list of implications for
occupational therapy training programs and directions for future research, can be found in
Chapter 8 of the guidelines.
Clinical Recommendations for Occupational Therapy Practice

The clinical recommendations for occupational therapy interventions for adults living with SMI
can be found in Chapter 9 of the guidelines. Table 9.1 provides the final grades for interventions
described in this Practice Guideline. The criteria for level of evidence and recommendations (A,
B, C, I, D) used in Table 9.1 are based on standard language from the U.S. Preventive Services
Task Force (2013). Recommendations are based on the available evidence and on content
experts’ clinical expertise regarding the value of using such evidence. Clinical recommendations
are provided after completion of the systematic reviews and full analysis of the data collected.
They are to be used to guide practice based on the findings of the reviews.
Bottom Line
Adults living with SMI can face several challenges, including difficulty accessing proper medical
care and treatment, social stigma, and challenges to engaging in meaningful everyday activities.
Occupational therapists have a role to play by helping clients living with SMI and their families
to gain, regain, or sustain employment, education, social engagement, and other desirable activi-
ties, while coordinating with health care practitioners for needed medical care. These practice
guidelines provide a resource to help practitioners find evidence-based interventions for adults
living with SMI and their families and provide a tool for advocacy with external audiences. They
also as highlight areas for future research and inquiry.
xv
Abbreviations and Acronyms
Used in This Publication
ACLS–5 Allen Cognitive Level Screen, 5th edition
ADHD attention deficit hyperactivity disorder
ADHS Adult Dispositional Hope Scale
ADLs activities of daily living
AIHQ Ambiguous Intentions Hostility Questionnaire
AIHQ–A Ambiguous Intentions Hostility Questionnaire–Ambiguous Situations
AIMS Abnormal Involuntary Movement Scale
ANOVA analysis of variance
AOTA American Occupational Therapy Association
APA American Psychiatric Association
AUDIT Alcohol Use Disorders Identification Test
BACS Brief Assessment of Cognition in Schizophrenia
BACS–J Brief Assessment of Cognition in Schizophrenia–Japanese version
BAI Beck Anxiety Inventory
BAS Burden Assessment Scale
BCIS Beck Cognitive Insight Scale
BDFQ Bipolar Disorder Functioning Questionnaire
BDI Beck Depression Inventory
BHS Beck Hopelessness Scale
BMI body mass index
BNCE Brief Neuropsychological Cognitive Examination
BPIS Birchwood’s Psychosis Insight Scale
BPRS Brief Psychiatric Rating Scale
BPRS–E Brief Psychiatric Rating Scale–Extended
BRFSS Behavioral Risk Factor Surveillance System
BSABS Bonn Scale for the Assessment of Basic Symptoms
BSI Brief Symptom Inventory
BVMT–R Brief Visuospatial Memory Test–Revised
CAARMS Comprehensive Assessment of At-Risk Mental States
CACR computer-assisted cognitive remediation/rehabilitation
CAQ–SPMI Change Assessment Questionnaire for People With Severe and Persistent
Mental Illness
CAS Cunningham Access Survey
xvi
A bbrevi ati o n s an d A c ro n ym s U sed i n Th i s Pub lication
CAT Cognitive Adaptation Training

CBASP Cognitive Behavioral Analysis System of Psychotherapy
CBSST Cognitive–Behavioral Social Skills Training
CBT cognitive–behavioral therapy
CBT–I cognitive–behavioral therapy for insomnia
CDS Calgary Depression Scale
CDSM chronic disease self-management
CDSMP Chronic Disease Self-Management Program
CES–D Center for Epidemiologic Studies Depression Scale
CESD–R Center for Epidemiologic Studies Depression Scale–Revised
CET cognitive enhancement therapy
C–GAS Children’s Global Assessment Scale
CGI Clinical Global Impression Scale
CGI–I Clinical Global Impression Scale–Improvement
CGI–S Clinical Global Impression Scale–Severity
CHR clinical high risk
CI confidence interval
CJSC Chinese Job Stress Coping Scale
CJTC Chinese Job Termination Checklist
CMT Comprehensive Module Test
COPM Canadian Occupational Performance Measure
CPT Continuous Performance Test
CPT–AX AX–Continuous Performance Test
CPT–IP Continuous Performance Test, Identical Pairs version
CR cognitive remediation
CRT cognitive remediation training
CSC Coping with Symptoms Checklist
CSSMIS Chinese Self-Stigma of Mental Illness Scale
CTMT Comprehensive Trail Making Test
CVLT California Verbal Learning Test
CVR conventional vocational rehabilitation
DAI Drug Attitude Inventory
DASH Dietary Approaches to Stop Hypertension
DASS Depression Anxiety Stress Scale
DPA Diversified Placement Approach
DPAS Defeatist Performance Attitude Scale
DSM Diagnostic and Statistical Manual of Mental Disorders
DVT Digit Vigilance Test
EF executive function
EI early intervention
xvii
EIS early intervention services

ER emergency room
ES effect size
ESE enhanced supported employment
ESS Ending Self-Stigma
FEIT Face Emotion Identification Test
FEP first-episode psychosis
FPE family psychoeducation
GAF Global Assessment of Functioning
GAS Global Assessment Scale
GDP gross domestic product
GDS Geriatric Depression Scale
GES Generic Environmental Supports
GF–R Global Functioning–Role scale
GF–S Global Functioning–Social scale
GFSC goal-focused supportive contact
HADS Hospital Anxiety and Depression Scale
HAM–D Hamilton Depression Rating Scale
HAM–D17 17-item Hamilton Depression Rating Scale
HAM–D21 21-item Hamilton Depression Rating Scale
HbA1c Hemoglobin A1c
HDRS Hamilton Depression Rating Scale
HIV human immunodeficiency virus
HMO health maintenance organization
HoNOS Health of the Nation Outcome Scale
HOPES Helping Older People Experience Success
HPA hypothalamic–pituitary–adrenal
HRQOL health-related quality of life
HRSD Hamilton Psychiatric Rating Scale for Depression
HVLT–R Hopkins Verbal Learning Test–Revised
IADLs instrumental activities of daily living
ICD International Statistical Classification of Diseases and Related Health
Problems
ICU intensive care unit
IDS Inventory of Depressive Symptomatology
ILS Independent Living Scales
ILSS Independent Living Skills Survey
IPAQ International Physical Activity Questionnaire
IPC Internality, Powerful Others, and Chance Multidimensional Locus of
Control Scale
IPS individual placement and support
xviii
ISE integrated supported employment

ISI Insomnia Severity Index
ISMI Internalized Stigma of Mental Illness Scale
IVIP Indianapolis Vocational Intervention Program
KASQ Knowledge About Schizophrenia Questionnaire
KIDI Knowledge of Illness and Drugs Inventory
KKW kilocalories per kilogram of body weight per week
K–SADS Schedule for Affective Disorders and Schizophrenia for School-Age
Children
LASMI Life Assessment Scale for the Mentally Ill
LoF level of functioning
LSMECD Lorig Self-Management Efficacy in Chronic Disease
M mean
MADRS Montgomery–Asberg Depression Rating Scale
MANSA Manchester Short Assessment of Quality of Life
MASC Maryland Assessment of Social Competence
MATRICS Measurement and Treatment Research to Improve Cognition in
Schizophrenia
MATRICS–NIMH Measurement and Treatment Research to Improve Cognition in
Schizophrenia–National Institute of Mental Health
MBCT mindfulness-based cognitive therapy
MBSR mindfulness-based stress reduction
MCAS Multnomah Community Ability Scale
MCCB MATRICS Consensus Cognitive Battery
MDD major depressive disorder
Mdn median
MES Modified Engulfment Scale
MET metabolic equivalent
MHI Mental Health Inventory
MHRM Mental Health Recovery Measure
MHS Miller Hope Scale
MIRRORS Mindfulness Intervention for Rehabilitation and Recovery in
Schizophrenia
MMSE Mini-Mental State Examination
MOHOST Model of Human Occupation Screening Tool
MSEI Multidimensional Self-Esteem Inventory
MSPSS Multidimensional Scale of Perceived Social Support
MVQ Maudsley Violence Questionnaire
MWS Makuhari Work Sample
NA not applicable
NAB Neuropsychological Assessment Battery
xix
NEAR Neuropsychological Educational Approach to Remediation

NECT Narrative Enhancement and Cognitive Therapy
NET neurocognitive enhancement therapy
NIMH National Institute of Mental Health
NSA–M Negative Symptom Assessment–Motivation
OEES Outcomes Expectation for Exercise Scale
1RM one-repetition maximum test
OSA Occupational Self-Assessment
OT occupational therapist/occupational therapy
OTA occupational therapy assistant
OT–PVP occupational therapy–led prevocational program
PAM Patient Activation Measure
PANSS Positive and Negative Syndromes Scales
PBEQ Personal Beliefs about Experiences Questionnaire
PDDS Perceived Devaluation–Discrimination Scale
PE physical exercise
PECC Psychosis Evaluation Tool for Common Use by Caregivers
PEP psychoeducational program
PHQ–9 Patient Health Questionnaire–Depression
PMRT progressive muscle relaxation training
POMS Profile of Mood States
PSP Personal and Social Performance
PSQ Perceived Stigma Questionnaire
PSQI Pittsburgh Sleep Quality Index
PTCS Psychosocial Treatment Compliance Scale
PTSD posttraumatic stress disorder
Q–LES–Q–SF Quality-of-Life Enjoyment and Satisfaction Questionnaire–Short Form
QLS Quality of Life Scale
QOL quality of life
QOLI Quality of Life Interview
R&R2MHP Reasoning and Rehabilitation Mental Health Program
RAVLT Rey Auditory Verbal Learning Test
RBANS Repeatable Battery for the Assessment of Neuropsychological Status
RBMT Rivermead Behavioural Memory Test
RCT randomized controlled trial
RPT relapse prevention therapy
RSES Rosenberg Self-Esteem Scale
RTI–E Routine Task Inventory–Expanded
RTW return to work
RWT Rockport Walking Test
xx
SAI State Anxiety Inventory

SAMHSA Substance Abuse and Mental Health Services Administration
SANS Scale for the Assessment of Negative Symptoms
SAPS Scale for Assessment of Positive Symptoms
SAS Social Attainment Scale
SBS Social Behavior Schedule
SCDSES Stanford Chronic Disease Self Efficacy Scale
SCDSMP Stanford Chronic Disease Self-Management Program
SCID Structured Clinical Interview for DSM–IV
SCIP Screen for Cognitive Impairment
SCIT Social Cognition and Interaction Training
SCL–20 Symptom Checklist Depressive Scale
SCST Social Cognitive Skills Training
SD standard deviation
SDS Social Distance Scale
SDSS Social Disability Screening Schedule
SEES Subjective Exercise Experiences Scale
SE/SE supported employment/supported education
SFS Social Functioning Scale
SF–12 12-Item Short Form Health Survey
SF–36 36-Item Short Form Health Survey
SIP Social Inclusion Program
SIPS Structured Interview for Prodromal Symptoms
SISST Social Interaction Self-Statement Test
SMD standard mean difference
SMI serious mental illness
SOFAS Social and Occupational Functioning Assessment Scale
SOFS Social and Occupational Functioning Scale
SOPS Scale of Prodromal Syndromes
SPSI–RS Social Problem-Solving Inventory–Revised: Short
SQ Status Questionnaire
SSDI Social Security disability income
SSI supplemental security income
SSIT Simulated Social Interaction Test
SSMIS Self-Stigma of Mental Illness Scale
SSPA Social Skill Performance Assessment
SSPI Social Skills for Psychiatric Inpatients
SSRI selective serotonin reuptake inhibitor
SSS Stigma Stress Scale
SST social skills training
xxi
STAI State–Trait Anxiety Inventory

SUMD Scale to Assess Unawareness in Mental Disorder
SVR standard vocational rehabilitation
TAG therapist-administered group
TAU treatment as usual
TMT Trail Making Test
Trails A Trail Making Test Part A
Trails B Trail Making Test Part B
TRENDS Tool for Recognition of Emotions in Neuropsychiatric Disorders
TSW Thinking Skills for Work program
TVR traditional vocational rehabilitation
TVS traditional vocational services
UCLA CHIPTS University of California, Los Angeles, Center for HIV Identification,
Prevention, and Treatment Services
UPSA University of California, San Diego, Performance-Based Skills Assessment
UPSA–B Brief University of California, San Diego, Performance-Based Skills
Assessment
USPSTF U.S. Preventive Services Task Force
VA Veterans Affairs
VCRS Vocational Cognitive Rating Scale
VLMT Verbal Learning Memory Test
VOC vocational training/rehabilitation
VO2 max maximal oxygen uptake
VR vocational rehabilitation
VRG virtual reality–based vocational training group
VR–JIT virtual reality job interview training
WAIS Wechsler Adult Intelligence Scale
WAIS–R Wechsler Adult Intelligence Scale–Revised
WBI Worker Behavior Inventory
WCPA Weekly Calendar Planning Activity
WCST Wisconsin Card Sorting Test
WHO World Health Organization
WHO–DAS World Health Organization Disability Assessment Schedule
WHOQOL World Health Organization Quality of Life assessment
WHOQOL–BREF World Health Organization Quality of Life Brief scale (abbreviated ver-
sion of WHOQOL)
WOD work-ordered day
WRAT Wide Range Achievement Test
WRAT–R Wide Range Achievement Test–Revised
WTAR Wechsler Test of Adult Reading
xxii
1. Overview of Serious
Mental Illness
T he National Institute of Mental Health (NIMH; 2017) classifies mental illness into two
broad categories: (1) any mental illness and (2) serious mental illness (SMI). In the United
States in 2016, an estimated 18.3% of adults aged 18 or older lived with mental illness. In other
words, 1 in 6 adults, or 44.7 million, experienced conditions identified as any mental illness,
which comprises all mental, behavioral, and emotional disorders as defined by NIMH. These
disorders cause a range of impairment from no impairment through degrees of mild, moderate,
and severe impairment.

A smaller subset of individuals living with mental illness are those experiencing SMI (NIMH,
2017). In the U.S. population, 4.2% of adults, or 10.4 million people aged 18 or older, lived
with SMI in 2016, with a slightly higher prevalence found in women (5.3%) than in men
(3.0%). Young adults aged 18–25 living with SMI had the highest prevalence (5.9%) compared
with adults aged 26–49 (5.3%) or 50 years or older (2.7%).
Defining the presence of SMI typically involves three characteristics of mental illness: (1)
diagnosis, (2) functional impairment, and (3) duration of illness (NIMH, 2017). The U.S.
Substance Abuse and Mental Health Services Administration (SAMHSA, 2017c) has defined
SMI as
having, at any time during the past year, a diagnosable mental, behavior, or emotional
disorder that causes serious functional impairment that substantially interferes with or
limits 1 or more major life activities. Serious mental illness is defined at the federal level
to include major depression, schizophrenia, bipolar disorder, and other mental disorders
that cause serious impairment.
According to NIMH (2017), disability resulting from SMI represents the greatest burden
for affected individuals. Living with SMI means those individuals are more likely to experience
unemployment, homelessness, or arrest (SAMHSA, 2017c). They experience underemployment
or unemployment at higher rates than people without mental illness (Luciano & Meara, 2014).
In 2010, approximately 38% of individuals living with SMI were employed, compared with
approximately 62% of people with no mental illness, and 39% of persons living with SMI had
incomes below $10,000 (Arbesman & Logsdon, 2011; Luciano & Meara, 2014). The 2016
Annual Homeless Assessment Report estimated that individuals living with SMI accounted for
25% of adults in homeless shelters (U.S. Department of Housing and Urban Development, 2016).
Estimates indicate that more than 350,000 individuals living with SMI are imprisoned in the
United States (Lamb & Weinberger, 2013, 2014). Swanson et al. (2013) estimated that approxi-
mately 2 million people living with SMI enter U.S. jails annually and experience recurring cycles
in the criminal justice system, reducing their lifetime opportunities for recovery and stability in
community settings. For youth being served by the juvenile justice system, approximately 70%
live with one or more mental health conditions, and approximately 25% experience these dis-
orders at a severe level (National Conference of State Legislatures, 2011). An understanding of
these statistics provides important support to the clinical programming efforts of early interven-
tion services for youth at high risk for psychosis, because these strategies may limit the negative
consequences of living with mental illness.
1
The consequences of lack of treatment for individuals living with SMI are staggering. Of U.S.
adults living with SMI in 2014, 63% received mental health services, compared with 41% liv-
ing with any mental illness (SAMHSA, 2015). Racial and ethnic discrepancies exist in treatment
use; African-Americans and Hispanic Americans use mental health services at about half the rate
of White Americans, and Asian Americans use services at about one-third the rate (SAMHSA,
2015). Regardless of whether individuals receive treatment, SMI results in total annual loss
of earnings of $99.5 billion per year in the United States, according to the World Health
Organization (WHO) Mental Health Survey (Levinson et al., 2010).
Mental illness disabilities now are recognized as resulting in extraordinarily high social and
economic costs to society and account for increasing years of life lost; depressive disorders have
the highest costs of all medical conditions (Murray et al., 2012). In 2016, disability claims based
on mental health–related issues represented approximately 25% of all disability claims (Social
Security Administration, 2017). In 2014, almost 6% of hospitalizations were attributable to
mental health and substance use disorders (McDermott et al., 2017).
In a landmark study by Colton and Manderscheid (2006), health consequences of SMI were
found to include increased risk of chronic medical conditions. Adults living with SMI experi-
ence premature death, dying on average 10–25 years earlier than others. Similarly, Walker et al.
(2015) reported findings from a systematic review and meta-analysis indicating that mortality
among people living with mental disorders occurred an average of 10 years earlier than among
the general population. Causes of early mortality were attributed primarily to the treatable
medical conditions of cardiovascular disease, obesity, lack of exercise, alcohol consumption, and
poor diet (Colton & Manderscheid, 2006; WHO, n.d.). This evidence presents a significant chal-
lenge of providing health care to meet the needs of this population, especially to enable these
individuals to be fully participating members of society.
Mental Disorders Considered SMI

Living with a mental disorder affects functioning across the various psychiatric diagnoses con-
sidered to be SMI (Bottlender et al., 2013). Yet, it is the severity of the illness, as indicated by
the severity of symptoms, that determines the level of impairment, rather than the diagnosis per
se. Additionally, cognitive impairments have been identified as a significant predictor of func-
tional status and are more consistently related to functioning than symptom severity (Bowie
et al., 2010; Gupta et al., 2012; Rock et al., 2014). Deficits in cognition components, such as
executive function (EF), memory, and attention, lead to functional disability that persists beyond
symptom remission. Negative effects of environments and contexts, such as financial limitations,
inadequate housing, lack of social supports, and discrimination, contribute to further reduction
in functioning (Montgomery et al., 2011). The most common SMI diagnoses that cause serious
impairment in occupational performance are schizophrenia spectrum disorders, bipolar disor-
ders, and major depressive disorders (SAMHSA, 2017c).
Schizophrenia Spectrum Disorders

Schizophrenia spectrum disorders, including schizophrenia and schizoaffective disorder, repre-
sent significantly disabling diseases, affecting many areas of social, family, psychological, voca-
tional, and occupational life (American Psychiatric Association [APA], 2013; Lyngdoh & Ali,
2016). These disorders rank among the most common causes of disability in the world. Quality
of life (QOL) is negatively affected by functional limitations due to interpersonal difficulties,
poor coping with stress, poor concentration, and lack of energy or initiative. Schizophrenia
spectrum disorders are characterized by psychotic symptoms in one or more of five domains:
(1) delusions, (2) hallucinations, (3) disorganized thinking (speech), (4) grossly disorganized or
abnormal motor behavior (including catatonia), and (5) negative symptoms (diminished emo-
tional expression and avolition; APA, 2013). Schizoaffective disorders display either active or
residual symptoms of psychotic illnesses, with episodes of depression or mania being present for
the majority of the illness duration.
In predicting overall psychosocial functioning, severity of negative symptoms is the most criti-
cal factor in poor outcomes (Milev et al., 2005). Cognitive functions of memory, attention, and
2
O vervi ew of Seri ou s M en tal Illness
EF lead to significant cognitive impairment in up to 75% of persons living with schizophrenia

(Talreja et al., 2013). Specifically, social cognition deficits have predictive value for reduction in
three major functional spheres: (1) independent living, (2) work and school, and (3) interper-
sonal contacts with friends and family (Green et al., 2018). Social cognition incorporates per-
ceiving social cues, sharing other peoples’ experiences, and inferring other people’s thoughts and
emotions (M. F. Green et al., 2015). Social cognition tends to have stronger associations with
social disability than nonsocial cognition, which comprises memory, attention, reasoning and
problem solving, and speed of processing (Fett et al., 2011). Although cognitive functions have
not been described as a diagnostic criterion, they have been recommended as a measure by APA
(Bhattacharya, 2015).
Bipolar Disorders
Bipolar disorders are characterized by instability of mood, which causes serious impairment
in work and social functioning through the presence of manic and depressive episodes (APA,
2013). Symptoms of mania may include “an abnormally, persistently elevated, expansive, or
irritable mood and persistently increased activity or energy” (APA, 2013). Most individuals
experiencing bipolar I disorder experience symptoms of full manic episodes and full depressive
episodes during their lives. The diagnosis of bipolar II disorders consists of “at least one episode
of major depression and at least one hypomanic episode” (APA, 2013) and is no longer consid-
ered a milder form of bipolar I disorder because of associated lifetime functional impairments.
Bipolar disorders typically affect adults by leading to functional impairment in roles of inde-
pendent living, employment and education, interpersonal and intimate relationships, and leisure
engagement (Sanchez-Moreno et al., 2017). Although to a lesser degree than in schizophrenia,
cognitive deficits in bipolar disorders nevertheless are one of the best predictors of functional
outcomes. Verbal memory and EF, in particular, appear to be critical determining factors of
functioning.
Major Depressive Disorders

Depressive disorders are characterized by sad, empty, or irritable mood, and changes are seen in
affect, cognition, and neurovegetative functions (APA, 2013). Diagnosis requires the presence of
either depressed mood or loss of interest or pleasure. Additionally, individuals may experience
changes in weight, appetite, sleep, fatigue, ability to concentrate, and ability to make decisions.
Feelings of worthlessness and guilt or thoughts of death and suicide may create risk and safety
concerns.
Overall, affective aspects of social functioning (subjective features such as loneliness, affilia-
tion, and perceived social disability) seem to be more hampered than behavioral ones (social net-
work size, frequency of social activities, and frequency of perceived social support; Saris et al.,
2017). Even after complete remission of affective psychopathology, residual impairments in
social functioning may exist, and social dysfunction can be predictive of future psychopathology.
Yet, compared with persons living with schizophrenia spectrum disorders or bipolar disorders,
persons living with depressive disorders experience greater improvements in social functioning
during symptom remission (Furukawa et al., 2011).
Co-occurrence and Other Considerations

Coexistence of both a mental health disorder and a substance use disorder is referred to as co-
occurring disorders (SAMHSA, 2017c). SAMHSA (2017b) estimated that in 2016, 2.6 million
adults aged 18 or older had co-occurring SMI and substance use disorders, representing 1.1%
of adults in the United States. Many individuals living with SMI have multiple mental disorders,
compounding the consequences of the primary mental disorder (Swarbrick & Noyes, 2018). In
addition to multiple mental disorders, individuals also experience comorbid medical illnesses
such as heart disease, diabetes, and neurological diseases. Thus, individuals living with these
frequently intertwined disorders require and benefit from health care practitioners’ attention to
coordinate all types of health care needs. These primary diagnoses of SMI may co-occur with
other psychiatric disorders, including anxiety, personality disorders, and substance use disorders,
compounding the consequences of the primary psychiatric diagnosis.
3
It is also important to recognize other conditions that affect the experience of living with
SMI. Homelessness is a critical concern for individuals living with SMI. Estimates indicate that
20%–30% of individuals persistently without a home are living with SMI (Office of National
Drug Control Policy, n.d.; SAMHSA, 2017a). A similar percentage of homeless individuals are
living with chronic substance use disorders. Given that these health conditions result in major
difficulties in accessing and maintaining stable, affordable, and appropriate housing, programs
such as supportive permanent housing are critical while homeless persons recover from sub-
stance use and mental disorders (Office of National Drug Control Policy, n.d.).
Individuals living with SMI experience interpersonal trauma and trauma-related disorders
at rates significantly higher than the general population (Mauritz et al., 2013). An estimated
one-third to three-quarters of individuals living with SMI experience a traumatic event,
including emotional abuse and neglect, physical neglect, complex posttraumatic stress dis-
order (PTSD), and dissociative disorders, at least once during their lifetime (O’Hare et al.,
2017). Among the traumatic experiences, repeated interpersonal trauma can result in both
PTSD and more severe trauma-related disorders of complex PTSD and dissociative disor-
ders, all of which have a negative impact on the experience of SMI (Mauritz et al., 2013).
The experience of homelessness may result in greater occurrences of abuse, crime, and
trauma, further intensifying the consequences of psychiatric disorders and social instability
(Ogden, 2014).
For individuals living with SMI, internalized stigma, or self-stigma, often leads to loss of
held or aspired identities and simultaneous adoption of community-held stigmatizing views
(Mashiach-Eizenberg et al., 2013). Approximately one-third of people living with SMI experi-
ence internalized stigma at high enough levels for stigma to be a significant barrier to recovery
(Yanos et al., 2011). Consequences of internalized stigma may include “feelings of shame, dimin-
ished sense of meaning in life, and lessened sense of empowerment, social support, and QOL”
(Mashiach-Eizenberg et al., 2013, p. 19). This increased hopelessness may lessen self-esteem and
self-efficacy, leading to the potential for avoidance of life goals (Corrigan et al., 2009; Mashiach-
Eizenberg et al., 2013).
Completed suicide rate estimates are 25 times higher for individuals living with SMI than
among the general population of people living with mood disorders such as depression or bipo-
lar disorders (Office of the Surgeon General & National Action Alliance for Suicide Prevention,
2012). For individuals living with schizophrenia, suicide deaths are estimated at 5%, a rate 20
times higher than that of the general population (Hor & Taylor, 2010). Elevated suicide rates for
individuals living with schizophrenia and bipolar disorder are related to the risk factors of his-
tory of suicide attempts, depression, not taking medications as prescribed, and drug and alcohol
misuse (WHO, n.d.). During first-episode psychosis (FEP), 12% of individuals are estimated to
have engaged in suicide attempts and suicide during treatment, and those in the first month of
treatment had the highest risk (Fedyszyn et al., 2014).
Sylvestre and colleagues (2018) categorized poverty as “a seemingly intractable problem”
(p. 153) for individuals living with SMI. Poverty inflicts damaging and distressing consequences
for daily life, critically interfering with recovery and individuals’ ability to live their desired lives.
Poverty for people living with SMI leads to barriers to sustaining housing, resulting in dispro-
portionate rates of mental illness among the homeless population. Food insecurity is greater
for those living with SMI than in the general population (Muldoon et al., 2013). Those who
experience chronic poverty often are dependent on government assistance and are without other
sources of income.
Insufficiency of finances is also a function of social status (Sylvestre et al., 2018). Individuals
living with SMI are more often marginalized and isolated and thus unable to gain financial sup-
port from family, friends, or others to meet their needs (Cook & Mueser, 2016; Sylvestre et al.,
2018). Neighborhoods available to those with limited income typically include other people
struggling financially and a shortage of available resources and services. Finally, access to afford-
able transportation and to technology is critical to sustaining food acquisition, maintaining
social relationships, and seeking services. Sylvestre and colleagues (2018) concluded that people
living with SMI are vulnerable to deprivation and that their limitations in acquiring basic needs
are related to the presence of stigma and discrimination in society, preventing them from access
to needed settings and resources.
4
These interwoven barriers to successful occupational engagement in community living for

individuals living with SMI are important considerations for the delivery of occupational ther-
apy services to this population. Intervention for people living with SMI needs to be provided in
an integrated and collaborative process. Any occupational therapy intervention approaches must
be holistic, comprehensive, and inclusive of relevant practice models for serving individuals liv-
ing with SMI. Appropriate services need to have a strengths-based focus at the individual level
and, at a broader level, address community and societal change through advocacy and popula-
tion-based interventions.
Occupational Therapy Perspectives for Individuals Living With SMI

Occupational therapy practitioners train in psychosocial and mental health interventions as part
of their educational experiences (AOTA, 2013b). As clinicians, they provide a holistic perspec-
tive, meaningful activities, and occupation-based interventions focused on helping clients gain,
regain, and sustain participation in everyday life. Thus, occupational therapy practitioners are
well suited to provide mental health rehabilitation services in a variety of inpatient, outpatient,
and community settings as essential team members and program developers.
Societal mental health needs continue to increase, but resources such as the number and qual-
ity of mental health providers and mental health care programs remain limited (WHO, 2012,
2017). Although occupational therapy has its roots in mental health practice in the United
States, occupational therapy practitioners’ recognition as providers of mental health services for
purposes of reimbursement varies from state to state (AOTA, 2017b), and many mental health
care teams and clients currently have limited access to occupational therapy practitioners and
services. Advocacy for the distinct value of occupational therapy services for individuals living
with SMI is needed through education focused on health care policy and service provision plan-
ning and through negotiation of funding policies addressing all reimbursement provisions.
Views of occupational therapy to enable individuals living with SMI to fully participate and
engage in community and society parallel the understanding of mental health. Krupa (2016, p. 4)
cited two definitions of mental health as evidence for this understanding:
1. State of well-being in which the individual realizes his or her own potential, can cope with
the normal stresses of life, can work productively and fruitfully, and is able to make a con-
tribution to her or his own community (WHO, 2001)
2. State of successful performance of mental functioning resulting in productive activities,
fulfilling relationships with other people, and the ability to adapt to change and cope with
adversity (U.S. Department of Health and Human Services, 2000).
Krupa (2016) suggested that psychological, emotional, and social functions are critical fea-
tures for individuals to achieve mental health. These functions or capacities are applied to the
daily demands and challenges of engaging in daily activities toward achieving overall health.
Identification of symptoms and impairment patterns related to psychological, emotional, and
social capacities determines the presence of mental illness, and the presence of disability and
duration of functional limitations are also considered. Yet, individuals experiencing SMI are
able to manage persistent symptoms and engage in healthy and meaningful lives. Positive men-
tal health can be seen in persons participating in productive and social activities, meeting daily
demands, contributing to society, and envisioning future occupational engagement. Thus, Krupa
defined the role of occupational therapy as enabling persons living with SMI to achieve health
and well-being through meaningful occupations.
To support health and wellness in individuals, occupational therapy practitioners address
both primary and secondary levels of prevention (AOTA, 2013a). Primary prevention is
designed to prevent and reduce unhealthy conditions, diseases, or injuries through identifying,
reducing, or eliminating risk factors for disease and injury. Strategies may include improved
nutrition, increased physical activity, smoking cessation, weight management, and screening
for physical medical conditions such as heart disease, diabetes, and cancer. For persons with
disabilities, secondary prevention involves limiting the development of secondary conditions
and their subsequent impact on function and QOL. For individuals living with SMI, address-
ing unhealthy primary or secondary conditions is critical to enabling satisfactory occupational
participation.
5
Key Components of the Recovery Perspective

The New Freedom Commission on Mental Health (2003) identified the recovery perspective to
be the foundation of best practices for individuals living with SMI:
After a year of study, and after reviewing research and testimony, the Commission
finds that recovery from mental illness is now a real possibility. The promise of the
New Freedom Initiative—a life in the community for everyone—can be realized. (p. 1)
SAMHSA (2012) developed a working definition of recovery as “a process of change through
which individuals improve their health and wellness, live a self-directed life, and strive to reach
their full potential” (p. 3). As part of the Recovery Support Strategic Initiative, SAMHSA (2012)
identified dimensions of health, home, purpose, and community to support recovery and offered
10 guiding recovery principles, which can be summarized as follows:
1. Hope: Hope is the catalyst for a motivating belief in a better future in which individuals
overcome challenges by confronting them; hope is fostered by others.
2. Person driven: Persons determine and direct their own life goals and journey toward
those goals with greatest autonomy and independence through the choice of services
and supports. In this way, they gain empowerment and control to obtain resources, use
strengths, and make informed decisions.
3. Many pathways: Pathways to recovery are based on individuals’ unique needs, strengths,
preferences, goals, culture, and backgrounds; are highly personalized; are nonlinear, with
growth and setbacks; and make use of multiple natural and professional supports.
4. Holistic: Recovery embraces individuals’ whole lives, including mind, body, spirit, and
community, and involves self-care, family, housing, education, employment, transporta-
tion, integrated physical and mental health care, faith and spirituality, and social and
community participation.
5. Peer support: Support from peers promotes mutual engagement and encourages sharing
of experiential knowledge and skills through social learning toward a sense of belonging,
supportive relationships, valued roles, and community. Giving to others enables a sense
of self toward recovery and well-being.
6. Relational: Support through others’ belief in and involvement with the individual offers
hope, encouragement, strategies, and resources to promote participation in healthy and
fulfilling life roles.
7. Culture: Sensitive and attuned services incorporate values, traditions, and beliefs and are
personalized to meet unique needs.
8. Address trauma: Mental health problems, alcohol and drug use, and related issues often
are associated with experiences of trauma, which need to be considered when offering
services and supports to foster safety, trust, collaboration for choice, and empowerment.
9. Strengths and responsibility: Individuals speak for themselves and enact responsibility for
their own recovery journeys with support from others, using the strengths and resources
of individuals, families, and communities. Action to address discrimination and to foster
social inclusion and recovery is an individual and community social responsibility.
10. Respect: The courage to seek recovery needs acceptance and appreciation by communi-
ties, systems, and society, including protecting rights and eliminating discrimination.
Individuals need to be supported to accept self, develop positive and meaningful self-
identity, and believe in self.
The recovery model has become the fundamental framework guiding international publicly
funded mental health services (SAMHSA, 2010). To support recovery, evidence-based interven-
tions often address strategies to enable persons to attain occupational engagement, identified as
sustained and successful participation in meaningful activities and social roles (Pitts & McIntyre,
2016). Although many definitions have been presented for recovery, they have agreed on criti-
cal concepts of connectedness, hope and optimism about the future, identity, meaning in life,
and empowerment. Another component of the recovery model is the incorporation of peers to
aid others living with SMI through social support (Chinman et al., 2014). A peer with previous
success in community engagement in recovery is able to facilitate hope, insights, and skills in
6
individuals as they engage in treatment and connect with community supports to develop a sat-
isfying life. Critical to the recovery model is the understanding and acceptance of the nonlinear
and dynamic experience of individuals as they move beyond experiences of illness and disability
to engage in life with action and participation.
Occupational Therapy’s Link to Recovery Perspectives

Being in recovery is the individual’s personal journey toward a life in which participation in val-
ued and meaningful activities enables a sense of purpose and control for self-direction (Krupa,
2014). Occupational therapy is well suited to enable individuals to move from passive and
helpless illness roles into personal agency, in which they develop control and a growing sense of
expectations for participating in the larger world. Intervention involves enabling actual doing
of life roles and engagement in occupations (Pitts & McIntyre, 2016). For occupational therapy
practitioners, forgoing control of the therapy process may be uncomfortable, yet respecting the
rights and potentials of individuals as they make choices and become empowered is the very
aspect of recovery that leads to fulfilling lives (Brown, 2012).
The principles of the recovery model are consistent with the occupation-based and client-
centered approaches of occupational therapy. Stoffel (2011) emphasized occupational therapy’s
client-driven process requiring practitioners to be sensitive to client concerns by facilitating per-
sonal routines and well-being to achieve meaningful occupational roles. The personal journey
through recovery moves across a continuum of health experiences in which persons find hope to
gain coping and adaptation, empowerment and self-determination, and social and community
integration. Skill development approaches in occupational therapy are critical to making this
possible for persons living with SMI. Wilcock (2006) conceptualized health as doing and becom-
ing through finding meaning, purpose, and belonging, and not simply as the absence of illness.
The role of enabling the person’s experience in recovery is a distinct contribution of occupa-
tional therapy through interventions focused on building new skills, enhancing existing skills,
creating opportunities, and modifying environments to enable participation in life (AOTA,
2013b, 2017b). Occupational therapy’s role in mental health is to provide distinct occupation-
based evaluation and intervention (AOTA, 2017b). Assisting persons to retain or develop inter-
ests and skills, in conjunction with identifying environmental supports and barriers, leads to
enabling healthy participation in desired and necessary daily occupations. The promotion of
competence through performance and participation addresses use of the individual’s strengths,
skill development, habit and routine development, and personal regulation strategies, as well
as task and environment modifications. Whether occupational therapy practitioners work with
clients’ existing support systems or facilitate the development of new supports and resources, the
targeted outcome is to promote successful occupational participation. AOTA (2016) described
the potential of actual doing of occupations to be transformative through the promotion of
adaptation. Through occupational therapy intervention, individuals have the potential to create
personal and social identities, connect with people in their communities, and experience ongoing
personal growth and development (Krupa et al., 2009).
This Practice Guideline describes the evidence for interventions within the scope of occupa-
tional therapy practice for individuals living with SMI in the categories of ADLs and IADLs,
rest and sleep, leisure, and social participation; employment and education; health and wellness;
early intervention; and internalized stigma. The findings of the systematic reviews provide guid-
ance to practitioners for selecting interventions that generate functional outcomes for commu-
nity participation. Implications for using these findings are addressed for occupational therapy
practice, research, and education. Case studies are presented to link this evidence to clinical
applications to support best practice for individuals living with SMI.
7
2. Systematic Review
Methodology and
Overview of Findings
Background
Since 1998, AOTA has instituted a series of evidence-based practice projects to assist members
with meeting the challenge of finding and reviewing the literature to identify occupational ther-
apy evidence and, in turn, using this evidence to inform practice (Lieberman & Scheer, 2002).
Following the evidence-based philosophy of Sackett (1989), AOTA’s projects are based on the
principle that the evidence-based practice of occupational therapy relies on the integration of
information from three sources: (1) clinical experience and reasoning, (2) preferences of clients
and their families, and (3) findings from the best available research.
A major focus of AOTA’s Evidence-Based Practice Program’s projects is an ongoing program
of systematic reviews of multidisciplinary scientific literature, using focused questions and stan-
dardized procedures to identify occupational therapy–relevant evidence and discuss its implica-
tions for practice, education, and research. An evidence-based perspective is founded on the
assumption that scientific evidence of the effectiveness of occupational therapy interventions can
be judged to be more or less strong and valid according to a hierarchy of research designs, an
assessment of the quality of the research, or both.
Evidence Evaluation
AOTA uses standards of evidence modeled on those developed in evidence-based medicine. This
model standardizes and ranks the value of scientific evidence for biomedical practice, as shown
in Table 2.1.
The systematic reviews for adults living with SMI were supported by AOTA as part of the
Evidence-Based Practice Project. AOTA is committed to supporting the role of occupational
therapy in this important area of practice. A literature search for studies with adults living with
SMI was completed for January 2008 through June 2016 for previously reviewed topics pub-
lished in the American Journal of Occupational Therapy and for January 1995 through June
2016 for the recently added topics of early intervention and internalized stigma. This review is
crucial because occupational therapy practitioners need access to the results of the latest and
best available literature to support interventions for adults living with SMI that are within the
scope of occupational therapy practice.
The systematic reviews focused on questions developed and reviewed by the review authors; a
multidisciplinary guideline development group of experts in the field that included practitioners, aca-
demic faculty, consumer and mental health organization representatives, researchers, and policymak-
ers; AOTA staff; and the research methodologist to the AOTA Evidence-Based Practice Project.
The following five focused questions from the review of occupational therapy interventions
for people living with mental illness framed the reviews:
1. What is the evidence for the effectiveness of interventions to improve and maintain partici-
pation and performance in ADLs, IADLs, social participation, leisure, and rest and sleep
for people living with SMI? (D’Amico et al., 2018)
2. What is the evidence for the effectiveness of interventions to improve and maintain partici-
pation and performance in employment and education for people living with SMI? (Noyes
et al., 2018)
8
S y stem a ti c Revi ew Meth o d o l o g y a n d Overvi ew o f Findings
Table 2.1. Levels of Evidence
Level Study Designs
Level I Systematic reviews of the literature, meta-analyses, and RCTs. In RCTs, participants are randomly
allocated to either an intervention or a control group, and the outcomes for the groups are compared.
Level II Two groups, nonrandomized studies (e.g., cohort, case-control)
Level III One group, nonrandomized studies (e.g., before and after, pretest–posttest)
Level IV Descriptive studies that include analysis of outcomes (single-subject design, case series)
Level V Case reports and expert opinions that include narrative literature reviews and consensus statements
Note. RCTs = randomized controlled trials.

Source. Sackett (1989).
3. What is the evidence for the effectiveness of interventions to improve physical health and
wellness and the integration of care for people living with SMI? (Brown, Ali, & Lund,
2018; Brown & Engelhardt, 2018; Brown, Geiszler, Lewis, & Arbesman, 2018; Brown &
Toenies, 2018)
4. What is the evidence for the effectiveness of early interventions to improve and maintain
performance in occupations for people living with SMI? (Read et al., 2018)
5. What is the evidence for the effectiveness of interventions to reduce internalized stigma
and self-stigma for people living with SMI? (Swarbrick, 2018)
Review Methodology
Search Terms
Table 2.2 lists the search terms related to population and specific to each systematic review
topic. A medical research librarian with experience in completing systematic review searches
conducted the search and confirmed and improved the search strategies. The medical research
librarian exported the search results into EndNote format. The research methodologist for the
project did the first review of the search results (citations), eliminating all articles not relevant
to the project. These results were exported to review authors in three formats—EndNote,
Microsoft Word, and tab delimited.
Databases Used
Databases and sites searched included MEDLINE, PsycINFO, CINAHL, ERIC, and OTseeker.
In addition, consolidated information sources, such as the Cochrane Database of Systematic
Reviews, were included in the search; these databases are peer-reviewed summaries of jour-
nal articles and provide a system for clinicians and scientists to conduct systematic reviews of
selected clinical questions and topics. Moreover, reference lists from articles included in the sys-
tematic reviews were examined for potential articles, and selected journals were hand-searched
to ensure that all appropriate articles were included.
Inclusion and Exclusion Criteria

Inclusion and exclusion criteria are critical to the systematic review process because they pro-
vide the structure for the quality, type, and years of publication of the literature that is incor-
porated into a review. The search was limited to peer-reviewed scientific literature published in
English. The intervention approaches examined were within the scope of practice of occupa-
tional therapy for adults living with SMI. The literature included in the search was published
between January 2008 and June 2016 for Questions 1, 2, and 3 and between January 1995
and June 2014 for Questions 4 and 5. The search excluded data from presentations, conference
proceedings, non–peer-reviewed research literature, dissertations, and theses. Studies included in
the reviews provide Level I, II, III, and IV evidence; Level IV evidence was included only when
higher-level evidence on a given topic was not found.
9
Table 2.2. Search Terms for the Systematic Reviews of Occupational Therapy Interventions for
Adults Living With SMI
Categories Key Search Terms
Patient or client anxiety disorder, bipolar disorder, chronic mental illness, homeless, major depressive disorder,
population mood disorder, personality disorder, psychosis, psychotic disorder, schizophrenia, serious and
persistent mental illness, serious mental illness, severe mental illness
Employment and career counseling, career planning, education, education exploration, educational planning,
education employment, job, job coaching, postsecondary education, sheltered workshop, supported edu-
cation, supported employment, vocational planning, vocational rehabilitation, volunteer, work
ADLs and IADLs, activities of daily living, child care, child rearing, cleaning, communication skills, community liv-
rest and ing skills, community mobility, cooking, driving, gardening, grocery shopping, grooming, home
sleep, leisure, management, home repair, home safety, household management, hygiene, independent living
and social skills, instrumental activities of daily living, ironing, laundry, leisure, life skills, listening skills,
participation living skills, meal planning, meal preparation, medication adherence, medication compliance,
medication management, menu planning, parenting, rest, routines, self-care, shopping, sleep,
social functioning, social networking, social participation, social skills, social skills training,
social support, supported parenting, technology, time management, time use, transportation
Health and exercise, health management, meditation, nutrition, obesity, physical activity, physical fitness,
wellness relaxation, self-management, sexual health, sports, strength training, stress management, stress
reduction, weight control, weight loss, yoga
Early intervention early identification, early intervention, early psychosis, family education, family support, first
episode psychosis, peer group, prevention, self-regulation
Stigma and discrimination, internalized stigma, peer support, prejudice, self-stigma, stigma
self-stigma
Study and trial appraisal, best practices, case control, case report, case series, clinical guidelines, clinical trial,
designs cohort, comparative study, consensus development conferences, controlled clinical trial, critique,
cross over, cross-sectional, double-blind, epidemiology, evaluation study, evidence-based, evi-
dence synthesis, feasibility study, follow-up, health technology assessment, intervention, longi-
tudinal, main outcome measure, meta-analysis, multicenter study, observational study, outcome
and process assessment, pilot, practice guidelines, prospective, random allocation, randomized
controlled trials, retrospective, sampling, single blind study, single subject design, standard of
care, systematic literature review, systematic review, treatment outcome, validation study
Note. ADLs = activities of daily living; IADLs = instrumental activities of daily living.
Overview of Search Results

Process
A total of 58,207 citations and abstracts were included in the search results. The AOTA
research methodologist completed the first scan of the search results’ titles to remove dupli-
cates, articles published in the wrong years or addressing the wrong population, and those
that were clearly not research. Several of the systematic reviews were carried out as academic
partnerships, in which academic faculty worked either with students or with other faculty as
a team. The remaining references were evaluated by the review teams for each question. The
full-text versions of potential articles were retrieved, and the review team determined final
inclusion in the review on the basis of predetermined inclusion and exclusion criteria.
A total of 253 articles were included in the final review: 224 Level I studies, 19 Level II stud-
ies, 9 Level III studies, and 1 Level IV study. Table 2.3 provides the number of studies included
in each question and related levels of evidence. The team working on each focused question
reviewed the articles according to their quality (scientific rigor and lack of bias) and level of evi-
dence. The teams then extracted each article included in the review into an evidence table that
provides a summary of the articles’ methods and findings.
10
S y stem a ti c Revi ew Meth o d o l o g y a n d Overvi ew o f Findings
Table 2.3. Number of Articles Included in the Systematic Reviews, by Topic and Level of
Evidence
Level of Evidence
Type of Intervention I II III IV V Totals
ADLs and IADLs, rest and sleep, leisure, and

50 6 5 0 0 61
social participation
Employment and education 47 8 1 1 0 57
Health and wellness 85 0 0 0 0 85
Early intervention 22 6 2 0 0 30
Internalized stigma 14 3 3 0 0 20
Totals 224 19 9 1 0 253
Note. ADLs = activities of daily living; IADLs = instrumental activities of daily living.
Table 2.4. Strength of Evidence
Strength Description
Strong Consistent evidence from at least 2 well-designed, high-quality RCTs
Moderate Consistent evidence from 1 RCT or 2 or more studies with lower levels of evidence
Limited Few, lower-quality studies available; some inconsistency in findings across studies
Mixed Inconsistent findings across studies
Insufficient Number and quality of studies too limited to determine a strength rating

Source. U.S. Preventive Services Task Force (2013).
AOTA staff and the research methodology consultant reviewed the evidence tables to ensure
quality control. All studies are summarized in full in the evidence tables (Appendix A). The risk
of bias of individual studies was assessed using the methods described by Higgins and colleagues
(2011). The method for assessing the risk of bias of systematic reviews was based on the mea-
surement tool developed by Shea et al. (2007).
Strength of Evidence
For each systematic review, the evidence is grouped into themes and described according to the
strength of the evidence (Table 2.4). Strength of evidence designations include a synthesis of the
level of evidence (I–IV), the quality of the evidence (risk of bias), and the findings of the studies
(significance of findings). By synthesizing these three evaluations, the authors provide important
information to readers about the level of certainty that the interventions resulted in the out-
comes shown. The strength of the evidence (level of certainty) is based on the guidelines of the
U.S. Preventive Services Task Force (USPSTF; 2013).
Before publication, this Practice Guideline was reviewed by a group of content experts (both
occupational therapy and non–occupational therapy) on adults living with SMI that included a
consumer representative. These reviewers were a multidisciplinary guideline development group
of experts in the field that included practitioners, academic faculty, researchers, policymakers,
AOTA staff, and the research methodology consultant to the AOTA Evidence-Based Practice
Project.
11
Benefits and Harms

This Practice Guideline is based on findings from systematic reviews of interventions to enhance
participation and occupational performance for adults living with SMI and was produced for
AOTA. The studies that met the inclusion criteria for these systematic reviews did not explicitly
report potential adverse events associated with the interventions evaluated in these studies. If
harms were noted, they would have been reported in the summary of key findings and would
have been taken into account in the determination of the recommendations. Before implement-
ing any new intervention with a client, it is always prudent for occupational therapy practitio-
ners to be aware of the potential benefits and harms of the specific intervention.
Clinical Reasoning
Occupational therapy practitioners should exercise clinical reasoning that is based on a sound
evaluation of the client’s strengths and limitations and an understanding of the intervention to
determine the potential benefits and harms of an intervention for an individual client. Clinical
reasoning is also required to translate the intervention protocols used in the reviewed studies
into client-centered, clinically feasible interventions.
12
3. Evidence for Interventions to
Promote ADLs and IADLs, Rest
and Sleep, Leisure, and Social
Participation
O ccupation, the core fundamental principle of the occupational therapy profession, is

defined in the Occupational Therapy Practice Framework: Domain and Process (AOTA,
2014) as “various kinds of life activities in which individuals, groups, or populations engage,
including activities of daily living, instrumental activities of daily living, rest and sleep, educa-
tion, work, play, leisure, and social participation” (p. S19). These areas are the most frequent
targets for intervention by occupational therapy practitioners, so using evidence to support these
interventions is critical.
In this chapter, evidence is presented for the effectiveness of occupational therapy interven-
tions to promote ADLs and IADLs, rest and sleep, leisure, and social participation for adults liv-
ing with SMI. Sixty-one articles were included in the systematic review (D’Amico et al., 2018);
of these articles, 50 provide Level I evidence, including 11 systematic reviews and 39 random-
ized controlled trials (RCTs). Table 3.1 outlines the levels of evidence and number of articles
reviewed for this category.
Interventions
Five major intervention types emerged during the analysis: (1) occupation-based, (2) psycho-
education, (3) skills training, (4) cognition-based, and (5) technology-supported interventions.
Several studies also identified the benefit of individualized, client-centered interventions. Many
of these interventions were reported under one of the five specific categories, and several studies
combined aspects or methods from more than one category. Results are reported according to
intervention methods relevant to all occupational performance areas.
Table 3.1. Levels of Evidence for Interventions to Promote ADLs and IADLs, Rest and Sleep,
Leisure, and Social Participation
Level of Evidence Study Design No. of Articles
I Systematic reviews and meta-analyses 11
I RCTs 39
II Two groups, nonrandomized studies (cohort, case-control) 6
III One group, nonrandomized studies (before and after, 5

pretest–posttest)
IV Descriptive studies that include analysis of outcomes 0

(single-subject design, case series)
Total 61
Note. ADLs = activities of daily living; IADLs = instrumental activities of daily living; RCTs = randomized controlled trials.
13
Occupation-Based Interventions
The evidence for the use of occupation-based interventions to promote ADLs and IADLs is mod-
erate, especially for those that used individualized client-centered goals. Six studies examined
interventions for life skills, empowerment, ADLs, IADLs, safe community participation, and
occupational goals: 2 Level I studies (1 systematic review and 1 RCT); 1 Level II study; and 3
Level III studies.
Thomas et al.’s (2011) systematic review produced limited evidence because of flaws in some
studies and inconsistency in findings across studies. Roldán-Merino et al.’s (2013) RCT showed
significant increases in independence in IADLs and significant improvement in levels of family
burden after an IADL support intervention. Katz and Keren’s (2011) Level II study found signifi-
cant improvements on measures of EF, activity, and participation for clients living with schizo-
phrenia using Occupational Goal Intervention.
Findings from the Level III studies included improved self-ratings of competence in meet-
ing basic needs (Helfrich & Chan, 2013); increased self-efficacy in healthy cooking, food safety
principles, and grocery shopping skills (Clark et al., 2015); and significantly improved ADL and
IADL performance for clients living with schizophrenia after individualized interventions in
residential settings (Lindström et al., 2012). These individualized interventions addressed specific
ADLs and IADLs identified by each client, such as shopping, meal preparation, and self-care,
and were conducted in context.
The evidence for use of leisure activities in intervention is moderate. Level I studies by Carta
et al. (2014) and Cramer et al. (2013) demonstrated moderate evidence for occupation-based
interventions to improve leisure activities. Participants engaged in leisure activities during the
interventions, but participation was not significantly improved or sustained afterward.
The evidence for occupation-based interventions for rest and sleep is moderate. An RCT by
Rethorst and colleagues (2013) found that exercise as a daily occupation, along with medica-
tion, resulted in significantly improved sleep regardless of exercise dosage in participants living
with nonremitted major depression disorder.
The evidence is strong for social participation interventions. Four Level I studies (Chen et al.,
2015; Cook et al., 2009; Štrkalj-Ivezić et al., 2013; Tatsumi et al., 2012) and 1 Level II study
(Fitzgerald, 2011) examined programs found efficacious in improving in social participation and
occupational engagement. Of these, the interventions in 4 studies (Chen et al., 2015; Cook et al.,
2009; Fitzgerald, 2011; Tatsumi et al., 2012) were provided by occupational therapy practitioners.
In Štrkalj-Ivezić et al. (2013), interventions were provided by a multidisciplinary team that included
an occupational therapist. Chen and colleagues’ (2015) Life Adaptations Skills Training resulted in
significant improvements in sleep, coping, and lifestyle and social participation, but most of the out-
comes for this study were measures of symptoms. Fitzgerald (2011) implemented the Social Inclusion
Program and found that participants demonstrated significant improvement in motivation for occu-
pational engagement and patterns of occupational behavior, indicating that this occupational therapy
program improved ADL performance and social participation in forensic services.
Insufficient evidence was found supporting animal-assisted therapy to improve social par-
ticipation and engagement for people living with schizophrenia. Two RCTs examined such pro-
grams and found inconsistent results (Berget et al., 2008; Chu et al., 2009).
Psychoeducation Interventions
Strong evidence supports manualized programs using psychoeducation methods to improve and
maintain ADL and IADL performance. Four Level I RCTs used psychoeducation as a major
method of intervention for people living with SMI (Chien et al., 2016; Levitt et al., 2009; Lin
et al., 2013; Salyers et al., 2014). Chien and colleagues (2016) found that participation in the
Adherence Therapy program resulted in significant improvement in ADLs, IADLs, relationships,
and living skills. Lin et al. (2013) and Salyers et al. (2014) found that the Illness Management
and Recovery program resulted in significant improvement in targeted functions of medication
and illness management. Levitt et al. (2009) demonstrated that attending illness management
classes for 6 months resulted in significant improvement in medication management, illness
management, and psychosocial function. Although implementation was different across studies,
all found significantly improved ADL and IADL performance by intervention participants com-
pared with control participants.
14
Evidence for Interventions to Promote ADLs and IADLs, Rest and Sleep, Leisure, and Social Participation
Two Level I systematic reviews found moderate evidence supporting psychoeducation pro-
grams to improve sexual activity safety (Pandor et al., 2015; Walsh et al., 2014). Methods
included education; role-playing; and social, communication, and assertiveness skills training.
Both articles reported increases in condom use, protected intercourse, and understanding of
HIV/AIDS, but the significance of these findings was not reported.
Response to psychoeducation interventions may vary by diagnosis. For instance, mixed evi-
dence was found for psychoeducation for adults living with refractive bipolar disorders and
schizophrenia spectrum disorders. Three systematic reviews compared psychoeducation to
treatment as usual (TAU) or placebo for participants living with these diagnoses (Batista et al.,
2011; Bond & Anderson, 2015; Xia et al., 2013). Batista et al. (2011) found improved social
function and medication adherence and reduced time in hospital for some participants. Bond
and Anderson (2015) found moderate evidence for the positive effect of psychoeducation on
medication adherence, especially when delivered in groups and not individually, whereas Xia
et al. (2013) found insufficient evidence for the role of psychoeducation for people living with
schizophrenia in these same areas.
Swildens et al. (2011) and vanderVoort et al. (2015) studied individualized methods of psy-
choeducation intervention. Using the Boston Psychiatric Rehabilitation Approach developed
by Anthony and Liberman (1986), Swildens and colleagues found significant improvement in
attainment of social participation goals and social contacts for adults living with SMI. Over the
course of a year, vanderVoort and colleagues found that a collaborative care program that for-
malized care coordination for individuals living with bipolar disorder and their multidisciplinary
care providers resulted in significant improvement in overall functioning and in autonomy, cog-
nition, and leisure time.
Skills Training Interventions

Five Level I studies provide varying strength of evidence for skills training interventions. Three
systematic reviews provide mixed evidence for skills training. Almerie and colleagues (2015)
found mixed results on the basis of quality of studies and interventions. Gibson et al. (2011)
found moderate to strong evidence supporting social skills training (SST) and moderate evi-
dence for life skills and IADL training and for neurocognitive training paired with life skills.
Tungpunkom and colleagues (2012) found no difference in outcomes between skills training and
control conditions and high risk of bias in all studies reviewed. They called for new, more rigor-
ous studies on this topic to determine the effectiveness of life skills training to improve ADL and
IADL performance. All 3 systematic reviews identified limited follow-up after intervention as a
common limitation.
Bartels, Pratt, Mueser, Forester, et al. (2014) and Mueser et al. (2010) conducted RCTs to
evaluate the year-long weekly skills training program Helping Older People Experience Success
(HOPES). Both studies found significant improvements in community living skills, health care
use, social functioning, and negative symptoms for older adults living with SMI, providing strong
evidence for the HOPES program. In another RCT, Rus-Calafell et al. (2013) provided SST and
found significant improvements in social skills, interpersonal communication, and QOL.
Cognition-Based Interventions
Insufficient evidence exists for the use of cognition-based interventions to improve ADLs and
IADLs on the basis of 21 Level I studies (1 systematic review and 20 RCTs), 2 Level II, and 2 Level
III studies. An RCT by Sánchez et al. (2014) found significant improvements in general assessment
of function, cognitive performance, social competence, and functional disability, but made no men-
tion of specific ADLs, for participants in REHACOP, a program encompassing neuropsychological
rehabilitation, cognitive remediation training (CRT), and functional adaptation skills training.
Two Level I RCTs (Farhall et al., 2009; Velligan et al., 2009) and 2 Level III studies (Kidd
et al., 2014; Matsunaga et al., 2010) used cognition-based intervention programs with incon-
sistent results. Farhall et al. (2009) and Matsunaga et al. (2010) combined cognitive–behavioral
therapy (CBT) with TAU and found conflicting results. Farhall et al. found no group differences,
whereas Matsunaga et al. found improvements in depressive symptoms and social functioning
that were maintained for 1 year in treatment-resistant patients, although the significance of these
findings was not reported.
15
Velligan et al. (2009) and Kidd et al. (2014) implemented the Cognitive Adaptation Training
(CAT) program, a formalized home-based intervention using environmental supports. In an
RCT, Velligan and colleagues found significantly improved grooming and hygiene among par-
ticipants who used program supports compared with generic environmental supports. Kidd and
colleagues, in a Level III study, found significant improvements in adaptive functioning, symp-
toms, and goal attainment in a small sample with ongoing support from case managers.
Strong evidence was found for cognition-based interventions to improve and maintain performance
in rest and sleep. Three Level I RCTs (Chan et al., 2012b; Chien et al., 2015; Taylor et al., 2015) and 1
Level II study (Hsu et al., 2015) found significant improvement in sleep outcomes for participants who
received cognition-based interventions of mindfulness practices, relaxation breathing, and CBT.
Strong evidence was found for cognition-based interventions combined with aspects of social
interaction or skills training to improve social participation. Five RCTs using cognition-based inter-
ventions with a social skills or relationship component found significant improvements in social
interactions, relationships, and QOL versus social skills alone or TAU (Briki et al., 2014; Bucci
et al., 2013; Granholm et al., 2013; Michalak et al., 2015; Tas et al., 2012). Nine Level I RCTs
(Cavallo et al., 2013; Gil Sanz et al., 2009; Granholm et al., 2009, 2014; Hasson-Ohayon et al.,
2014; Horan et al., 2011; Poletti et al., 2010; Roberts et al., 2014; Taylor et al., 2016) and 1 Level
II study (Yip et al., 2013) evaluated social cognition–based programs. All reported significantly
improved cognitive functions but mixed social performance outcomes. Hasson-Ohayon et al.
(2014) and Taylor et al. (2016) investigated implementation of the Social Cognition and Interaction
Training (SCIT) program. Hasson-Ohayon et al. found significantly improved social engagement
outcomes after combining SCIT with social mentoring. Taylor et al. found significantly improved
facial affect recognition for participants living with schizophrenia. A computerized CRT program
combined with standard rehabilitation treatment resulted in significantly improved interpersonal
relations at 6-and 12-month follow-up compared with standard treatment (Poletti et al., 2010).
A systematic review by De Silva et al. (2013) evaluated psychosocial interventions of CBT,
SST, exercise, alternative therapies, and art therapy. They found moderate evidence for improved
social functioning for participants living with depression but mixed evidence for participants liv-
ing with schizophrenia.
Technology-Supported Interventions
Technology use as part of intervention for SMI has become more frequent, although the evi-
dence regarding the effect on IADLs is insufficient. A Level I RCT by Kaplan et al. (2014)
addressed parenting skills online, and 2 Level II studies (Lin et al., 2008; Pijnenborg et al., 2010)
reported positive results for the effectiveness of technology when combined with other interven-
tions. No study yielded significant results, and further study is required to identify any long-
term effects. Pijnenborg et al. (2010) used short text messages in addition to a psychoeducation
program and found significant improvement in doing and maintaining IADLs, but performance
dropped below baseline with withdrawal of the text messages.
Moving Research Into Practice

This review of evidence in the fundamental areas of occupation—ADLs, IADLs, rest and sleep,
leisure, and social participation—found a significant increase in studies of occupation-based
interventions and outcome measures in programs implemented by occupational therapy prac-
titioners since the last systematic review (Gibson et al., 2011). It also offers strong evidence in
support of occupational therapy interventions with adults living with SMI in meaningful areas
of their everyday lives. Interventions that included manualized psychoeducation programs
focused on illness management, self-care, medication adherence, problem-solving behaviors,
community interactions, IADLs, relationships, and communication were shown to be effective.
Holistic client-centered individualized programming, whether conducted in group settings or
individually, also resulted in improved performance in ADLs and IADLs, rest and sleep, leisure,
and social participation. Because these areas are prime targets for occupational therapy inter-
vention for adults living with SMI, practitioners can confidently use the strong evidence in this
review to inform their practice. The need remains for high-quality research that investigates
occupation-based interventions and reports on occupation-based outcome measures.
16
4. Evidence for Interventions
to Support Employment and
Education
M ost adults living with SMI desire to work or engage in education programs, in accordance
with typical adult roles, and perceive education and employment as valuable in the recov-
ery process (Dunn et al., 2008; Fernando et al., 2017). The value of employment includes poten-
tial increases in financial stability, social interactions, self-esteem, and community integration
(Koletsi et al., 2009). The majority seeking employment also report a need for more skills train-
ing and favorably view vocational services in both clubhouse and clinical settings (McQuilken
et al., 2003).
In spite of these recognized benefits of work and education, however, adults living with SMI
struggle to gain competitive employment. The National Institutes of Health, reporting data from
2009 and 2010, showed that adults living with mental illness had substantially lower employ-
ment rates and much lower wages than the general population (Luciano & Meara, 2014). For
adults living with SMI, barriers to obtaining and maintaining employment include personal
factors such as psychiatric symptoms, minimal or no previous working experience, reduced
confidence and motivation, and being out of work for a long duration. External barriers include
restricted job markets, complex job search procedures, nonsupportive working conditions, lack
of meaningful work, and stigma associated with mental illness (Koletsi et al., 2009; Milfort
et al., 2015). In the United States, concern over losing disability benefits in exchange for low pay
is one of the most prevalent deterrents to seeking employment (McQuilken et al., 2003).
Research has revealed common trends in overcoming barriers to competitive employment.
For instance, effective cognitive skills are critical to successful work performance (Arbesman &
Logsdon, 2011; Areberg & Bejerholm, 2013), and evidence indicates that improvement in atten-
tion and vigilance in adults living with SMI may correspond with improved vocational outcomes
(Puig et al., 2016). Further, Lexén and Bejerholm (2016) demonstrated that higher-quality com-
munication and interaction skills (e.g., asking questions, sharing information, sustaining conver-
sation in an appropriate manner) were significantly correlated with increased working hours and
higher income for adults living with SMI.
Barriers to education include previous negative educational experiences, sporadic attendance
at school because of psychiatric symptoms, feelings of frustration and apathy, and withdrawal
from school before graduation (Fernando et al., 2017). Although supported education programs
are designed to address these barriers, few formal supported education programs currently exist
in the United States, and occupational therapy practitioners seldom deliver them (Gutman et al.,
2009).
An AOTA systematic review by Noyes et al. (2018) examined evidence to support the role
of occupational therapy practitioners in the areas of employment and education for adults liv-
ing with SMI. Fortunately, this is a frequently and rigorously studied topic; of the 57 articles
included in the review, 47 provide Level I evidence (8 systematic reviews and 39 RCTs), 8 pro-
vide Level II evidence, 1 provides Level III evidence, and 1 provides Level IV evidence. Although
very few studies were conducted by occupational therapy researchers, all included studies were
within the scope of occupational therapy practice. Table 4.1 outlines the levels of evidence and
number of articles reviewed. Three themes for effective interventions emerged from the review:
(1) the individual placement and support (IPS) model, (2) cognitive interventions, and (3) sup-
ported education programs.
17
Table 4.1. Levels of Evidence for Interventions to Support Employment and Education
I RCTs 39
II Two groups, nonrandomized studies (cohort, case control) 8

pretest–posttest)

Total 57
Interventions
Individual Placement and Support Interventions
The IPS model of supported employment has been researched consistently since its inception, provid-
ing strong evidence for its effectiveness (Mueser & Cook, 2016). This service provision model is based
on eight key elements that hold competitive employment as the goal and privilege clients’ choices and
preferences throughout the process. Other key elements of IPS include a rapid job search, unlimited
individualized support, and integration of the client’s vocational and mental health teams (Bond et al.,
2012). Of the studies appraised for IPS, 31 were Level I studies (24 RCTs, 4 systematic reviews, and 3
meta-analyses), 5 were Level II studies, and 1 was a Level IV study. The majority of Level I studies com-
pared IPS to traditional vocational rehabilitation (TVR), and others compared IPS to novel interven-
tions including occupational therapy, mindfulness-based stress reduction (MBSR), and classical music.
Four Level I systematic reviews showed positive effects of IPS intervention. Three deter-
mined that IPS significantly increased competitive employment rates for adults living with SMI
(Arbesman & Logsdon, 2011; Bond et al., 2008; Gibson et al., 2011), and 1 showed that IPS
significantly increased levels of any employment obtained during the studies (Kinoshita et al.,
2013). In 2 meta-analyses, Campbell et al. (2010, 2011) found that IPS resulted in significantly
better competitive employment rates for all participants except those who had more than a high
school education or who were separated or divorced. Another meta-analysis determined that the
initial benefits of IPS intervention continued over 2 years (Modini et al., 2016).
Eight of 11 RCTs found IPS significantly more effective than TVR in improving vocational
outcomes; participants demonstrated double the rates of competitive employment and job ten-
ure, more hours worked and higher total income, and improved QOL (Areberg & Bejerholm,
2013; Catty et al., 2008; Heslin et al., 2011; Kin Wong et al., 2008; Kukla & Bond, 2013;
Michon et al., 2014; Twamley et al., 2008, 2012). The other 3 RCTs showed less success for IPS.
Burns et al. (2009) found that working at all—whether in IPS or TVR—resulted in improvement
in symptoms and social function for all participants. Howard et al. (2010) believed that the con-
text in which their study was conducted—a socioeconomically deprived area with a somewhat
rigid welfare benefits system, with intervention provided by an external agency—negatively
influenced the successful implementation of IPS. Poremski et al. (2017) noted that although
participants in an IPS intervention trended toward increased rates of competitive employment,
results did not reach significance.
Eleven Level I RCTs compared IPS to other types of vocational intervention, including job
club, clubhouse model, occupational therapy–specific programs or interventions, and integrated
supported employment (ISE; Au et al., 2015; Bond, Kim, et al., 2015; Burns et al., 2009; Cook
et al., 2008, 2016; Davis et al., 2015; Hees et al., 2013; Hoffmann et al., 2012, 2014; Mueser
et al., 2014; Shih et al., 2015). Bond, Kim, et al. (2015) compared IPS to a job club intervention
and reported similar outcomes on all measures except competitive employment rates, which
18
E v i d e n ce fo r In terven ti o n s to Su ppo rt Em pl o ym en t a n d Education
were 31% for IPS and 7% for job club participants—a significant difference. Four studies used
supported employment methods derived from but not using the IPS model (Cook et al., 2008,
2016; Hoffmann et al., 2012, 2014) and found similarly significantly higher rates of competitive
employment for those in the supported employment programs versus variations of TVR.
Mueser et al. compared IPS to a psychosocial clubhouse intervention and found that IPS
demonstrated statistically significantly better competitive work outcomes across all measures
of competitive employment, including a competitive employment rate four times higher (73%)
than that for the clubhouse (18%). Hees et al. (2013) added occupational therapy to TAU and
compared work participation, at-work and health-related functioning, and coping skills to a
TAU-only condition. Although nearly all participants (91%) achieved at least partial return to
work, no significant benefit for work participation was attributable to occupational therapy.
However, occupational therapy intervention increased the probability of long-term return to
work, long-term depression recovery, and a reduced need for other high-cost medical treatment
during intervention.
Four studies investigated the use of ISE, which is IPS plus SST. H. W. H. Tsang et al. (2009,
2010) compared ISE to IPS only and to TVR only, and Waghorn and colleagues (2014) com-
pared ISE to non–ISE, with all studies showing significantly better competitive employment rates
for participants in the ISE program. Au et al. (2015) added CRT to ISE and compared it to ISE
only. Both programs resulted in improvement in vocational outcomes, with no evidence that
CRT contributed to improvements beyond those already associated with ISE.
Two RCTs addressed unique vocational interventions. Davis et al. (2015) studied a ver-
sion of MBSR that was modified for people living with schizophrenia and called MIRRORS
(Mindfulness Intervention for Rehabilitation and Recovery in Schizophrenia). Although no
outcomes reached statistical significance, participants in the MIRRORS program demonstrated
clinically significant improvements by sustaining work longer and performing better at a work
placement than those in the control condition. Shih et al. (2015) studied the effect of back-
ground classical music on work attention for adults living with schizophrenia and found statisti-
cally significant improvement on an assessment of attention.
Five Level II studies also support the effectiveness of IPS. For instance, van Veggel et al.
(2015) found a statistically significant positive difference in competitive employment rates after
IPS compared with conventional vocational rehabilitation (VR). Competitive employment rates
during the 12 months of the study were nearly twice as high for IPS (24.9%) as for conven-
tional VR (14.3%). The psychosocial clubhouse model was investigated in 2 Level II studies.
Schonebaum and Boyd (2012) found that the work-ordered day that provides daily structure in
clubhouses had a positive impact on total employment duration when delivered before employ-
ment but had a negative relationship to total employment duration when delivered during
employment. In A. W. Tsang et al.’s (2010) study, employment rates were significantly higher
for clubhouse participants than for control participants. Using standard VR for intervention,
Watzke et al. (2009) showed a statistically significant positive difference in employment status
and more competitive employment at 9-month follow-up compared with TAU.
Rouleau et al. (2009) tested an occupational therapy–led prevocational program (OT–PVP),
based on Anthony and Liberman’s (1986) model of skills training, that combined cognitive–
behavioral and skills training and psychosocial approaches. Participants in OT–PVP achieved
volunteer or paid work at over four times the rate (71%) of the TAU group (16%) and showed
a statistically, but not clinically, significant reduction in negative symptoms on the Positive and
Negative Syndromes Scales and in general symptom scores at discharge.
A Level IV retrospective cohort study (Chuang et al., 2015) found four variables—education,
hand function, core strength, and vocational counseling—that reached statistical significance in
determining employment outcomes for individuals who participated in a prevocational program
during psychiatric inpatient admission. Chu’s (1997) Occupational Assessment Inventory was used
to evaluate physical fitness for work, and individuals who had hand function levels of good, fair, or
mild impairment and core strength at the level of excellent, good, or average were more likely to be
employed in sheltered, supported, or competitive employment. The same was true for participants
who had an associate or college degree and vocational counseling services posttraining. Overall,
Noyes et al. (2018) found strong evidence supporting the use of IPS for intervention to promote
employment on the basis of consistently positive results from numerous well-conducted studies.
19
Cognitive Interventions
Since Green’s (1996) landmark review of the functional consequences of neurocognitive deficits
for people living with schizophrenia, subsequent research has continued to identify cognition as
a prime target for intervention to support functional recovery. Eighteen studies—1 Level I meta-
analysis, 14 Level I RCTs, 2 Level II studies, and 1 Level III study—identified CRT methods that
offered improved outcomes in both cognitive skills and employment for adults living with SMI.
Although a few studies presented potential biases, the evidence for the use of cognitive interven-
tions to support employment is strong.
The meta-analysis (Chan et al., 2015) found that computer-assisted cognitive remediation
enhanced productivity outcomes—identified as employment rates, total days of work in a year,
and total annual earnings—for people living with SMI. The 14 RCTs studied other forms of
cognitive intervention, some individually and some in combination with vocational program-
ming. For instance, Hodge et al. (2010) used the Neuropsychological Educational Approach to
Remediation (NEAR) to provide cognitive remediation to 40 adults living with schizophrenia.
Although the average effect size was mild to moderate, participants demonstrated significant
improvement in visual and verbal memory, sustained attention, and EF and maintained these
improvements at least 4 months after treatment ended. However, the interventions were not pro-
vided in a work or vocational rehabilitation setting, so employment outcomes were not reported.
Two RCTs by Bell et al. (2008a, 2008b) compared participation in VR programs (vocational
training/rehabilitation [VOC]; control condition) to neurocognitive enhancement therapy (NET)
plus a vocational program. The NET intervention included 10 hours per week of computerized
cognitive exercises and participation in two work-related group sessions. In both studies, NET
resulted in significantly improved vocational outcomes. Participants in NET plus VOC worked
more total hours and had higher quarterly employment rates during the follow-up period.
Conversely, participants in the VOC-only condition showed a steady decline in employment
during the second year of the study. Another RCT found that cognitive enhancement therapy
(CET), which integrates interventions for neurocognition and social cognition, resulted in statis-
tically significant improvements in competitive employment, wages earned, and satisfaction with
employment status among outpatients in the early course of schizophrenia (Eack et al., 2011).
With specific attention to a population of adults living with SMI who had not benefited from pre-
vious participation in high-fidelity supported employment programs, McGurk et al. (2015) compared
participation in the Thinking Skills for Work program plus an enhanced supported employment
program to the enhanced supported employment program only. Participants in the Thinking Skills
for Work group showed statistically significant improvement on measures of cognitive functioning
compared with those in the enhanced supported employment–only group. They also had consistently
better competitive employment outcomes during the follow-up period, with nearly double the num-
ber of jobs obtained and wages earned and more than double the number of weeks worked.
Five RCTs focusing on cognitive function as a critical element in employment found CRT to
be effective. In 3 studies, participants experienced statistically significant improvements in cogni-
tive abilities including attention, concentration, and working memory (Lee, 2013) and verbal
learning and EF (Bio & Gattaz, 2011; McGurk et al., 2009). Tan and King (2013) found sta-
tistically significant improvements in neurocognition using rehearsal and strategy development
approaches, with participants maintaining those improvements for at least 1 year. After cogni-
tive rehabilitation training, participants in a study by Tao et al. (2015) demonstrated statistically
significantly higher employment rates than the control group.
A CBT intervention was used in 2 RCTs and contributed to statistically significant improve-
ment in vocational outcomes (Kukla et al., 2014; Lysaker et al., 2009). Finally, in 2 RCTs using
virtual reality interventions, participants received more job offers (Smith et al., 2015) and expe-
rienced statistically significant improvement in cognition measures (Tsang & Man, 2013).
In Level II studies using CRT interventions, Quee et al. (2014) found that CAT plus TAU
resulted in statistically significantly more hours spent in work-related activities than TAU only,
and Sato and colleagues (2014) compared CRT plus supported employment with supported
employment only and found no statistically significant between-group difference in employment
status. A Level III study by McGurk et al. (2010) reported that participants in the Thinking
Skills for Work program at a psychosocial clubhouse worked more competitive hours per month
and had statistically significant improvements in overall cognitive composite scores.
20
E v i d e n ce fo r In terven ti o n s to Su ppo rt Em pl o ym en t a n d Education
Supported Education Interventions

Only 2 supported education studies met the inclusion criteria for this review, and they provide
only moderate evidence because of inconsistency of results within and across the studies. A
Level I quasi-experimental study of the Bridge supported education program using occupational
therapy intervention showed statistically significant between-group differences on all five mea-
sures of the program’s effectiveness (Gutman et al., 2009). While engaged in the Bridge program,
participants increased their skill level in basic academic areas, improved professional behaviors
and social skills needed for school and work settings, and gained the confidence to test their
skills in the larger community. Factors that correlated most with success in the program included
adherence to a medication routine, possession of a stable residence, and motivation to attend the
program regularly.
A Level I RCT by Kidd and colleagues (2014) added CRT to supported education interven-
tions and showed that although both treatment and control groups demonstrated improvements
in cognitive functioning, CRT did not facilitate improvement in cognition above and beyond
gains associated with supported education. Although not statistically significant, improvements
in academic functioning were associated with CRT, and the treatment group showed a greater
rate of completion of the first semester.

The typical age of onset for SMI, during emerging adulthood, coincides with the developmental
tasks of completing education and beginning to work. The cognitive impairments that co-occur
with SMI can cause more interruption in occupational performance than the symptoms of the
illness itself (Bell et al., 2008a; Kidd et al., 2014), negatively affecting school and work perfor-
mance. Yet, adults living with SMI desire to engage in age-appropriate life roles of student and
worker despite the barriers to education and employment presented by those illnesses (Gutman
et al., 2009; McGurk et al., 2015).
In the interest of facilitating successful occupational performance in these areas, occupational
therapy practitioners are uniquely trained to take personal, contextual, and occupational factors
into consideration; determine how imbalances may result in decreased occupational performance;
and subsequently devise interventions to address these imbalances. For instance, regarding
employment, Davis and Rinaldi (2004) applied this process in their study on the implementation
of an evidence-based vocational program by occupational therapists for adults living with mental
health concerns, concluding, “It is the profession’s capacity to explore the more complex roles,
tasks and meaningful activities that determine the quality of an individual’s life that enables occu-
pational therapists to guide individuals to make the right vocational choices” (p. 322).
From a practice perspective, this review of evidence is especially useful because it addresses
only interventions within the scope of occupational therapy practice and provides strong evidence
for most of those interventions. For example, strong evidence supports the effectiveness of the IPS
model as an intervention for adults living with SMI who are seeking employment, and occupa-
tional therapy practice aligns seamlessly with both the key vocational elements of IPS and its focus
on nonvocational goals like developing social connections and enhancing community participa-
tion (Areberg & Bejerholm, 2013). With expertise in promoting full engagement for adults living
with SMI in student and worker roles, occupational therapy practitioners are well positioned to
use current evidence as leaders and team members in both IPS and supported education programs.
Similarly, occupational therapy practitioners’ training in cognition and its relationship to
occupational performance provides a firm foundation for using the strong evidence for cog-
nitive interventions in this review. Notably, many studies showed the strongest results when
CRT strategies were used not in isolation but in combination with occupation-based group
therapy or other occupation-based modalities. Embedding CRT for attention, memory, and
EF impairments in client-relevant occupations requires the expertise of occupational therapy
practitioners and directly targets improvement of clients’ occupational performance in work
and education (AOTA, 2018). Therefore, occupational therapy practitioners should routinely
provide these interventions to eligible clients on the basis of the good evidence found that
the interventions improve important outcomes and that benefits substantially outweigh harm
(USPSTF, 2013).
21
Promote Health and Wellness
O ccupational therapy’s essence is to help individuals achieve “health, well-being, and partici-
pation in life through engagement in occupation” (AOTA, 2014, p. S2), recognizing that
health comprises “physical, mental, and social well-being, and not merely the absence of disease
or infirmity” (WHO, 2006, p. 1). Occupational therapy supports wellness, defined as satisfaction
with one’s life situation (Schell et al., 2014). Scott and Happell (2011) stated that lifestyle behav-
iors may be a primary intervention target in efforts to reduce discrepancies in physical health
between mental health consumers and the general population. A landmark study by Colton and
Manderscheid (2006) found that people living with SMI died an average of 25 years earlier than
the general population because they were less likely to engage in healthy lifestyle behaviors.
Similarly, according to Scott and Happell (2011), people living with SMI have higher rates of
cardiovascular disease, infectious disease, diabetes, respiratory disease, and cancer.
Cardiovascular disease is linked to preventable conditions, including obesity (Colton &
Manderscheid, 2006). Obesity rates are alarmingly high in the general population, and the preva-
lence of obesity is even higher among people living with SMI. People living with SMI tend to lead
a more sedentary lifestyle than the general population, which is partially attributed to affective
factors such as depression and anxiety (Jerome et al., 2009), and fewer than 20% of people living
with schizophrenia engage in exercise (Bartels & Desilets, 2012). Most individuals living with SMI
take antipsychotic medications, which are associated with weight gain (Manu et al., 2015). People
living with SMI tend to have poor diets that are low in fiber and fruit and high in saturated fat
(Dipasquale et al., 2013). Low socioeconomic status challenges healthy eating because of the higher
costs of nutritious foods like fruits and vegetables. The combination of all these factors makes
weight loss challenging for people living with SMI (Brown, Geiszler, Lewis, & Arbesman, 2018).
This chapter summarizes the evidence for the effectiveness of occupational therapy inter-
ventions to promote health and wellness in people living with SMI. Eighty-five articles were
included in the systematic review; only Level I evidence was used because of the extensive num-
ber of studies at this level (Table 5.1; Brown, Ali, & Lund, 2018; Brown & Engelhardt, 2018;
Brown, Geiszler, Lewis, & Arbesman, 2018; Brown & Toenies, 2018).
Table 5.1. Levels of Evidence for Interventions to Promote Health and Wellness
I RCTs 64
II Two groups, nonrandomized studies (cohort, case control) 0

pretest–posttest)

Total 85
22
E v i den c e f o r In terven ti o n s to Pro m o te H ea l th a n d Wellness
Table 5.2. Levels of Evidence for Health and Wellness Interventions, by Theme
Level of Evidence and Design Physical Health Relaxation Exercise Weight Loss
Level I systematic reviews and meta-analyses 6 4 9 2
Level I RCTs 9 13 25 17
Level II 0 0 0 0
Level III 0 0 0 0
Total 15 17 34 19
Interventions
Critical appraisal of the evidence revealed four themes: (1) physical health, (2) relaxation, (3)
exercise, and (4) weight loss. Physical health interventions promote the absence or reduction of
chronic medical diseases and the implementation of healthy lifestyles (Scott & Happell, 2011).
Unhealthy lifestyles, characterized by poor diet, low physical activity, smoking, drug and alcohol
abuse, or risky sexual behavior, are all prevalent in SMI populations. Relaxation interventions
consist of strategies (e.g., yoga, muscle relaxation, meditation, tai chi) implemented to reduce
overall psychopathology, including negative and positive symptoms, and improve health-related
QOL (HRQOL; Vancampfort, Vansteelandt, et al., 2012). Exercise interventions consist of
physical activity strategies for preventing disease and promoting health and well-being, includ-
ing mental health. Exercise can be effective in reducing anxiety, depression, and negative mood
and improving self-esteem and cognitive functioning and thus is associated with improvements
in QOL (Callaghan, 2004). Weight loss interventions are lifestyle interventions for weight reduc-
tion and weight gain prevention (Bruins et al., 2014). Table 5.2 presents the number of articles
and levels of evidence for each of the four themes.
Physical Health Interventions

Strong evidence from 15 Level I studies supports interventions to promote the physical health of
people living with SMI. Nine studies were RCTs (Bartels, Pratt, Mueser, Naslund, et al., 2014;
Battersby et al., 2013; Chafetz et al., 2008; Druss et al., 2010; Goldberg, Dickerson, et al., 2013;
Kelly et al., 2017; Kelly, Fulginiti, et al., 2014; Lambert et al., 2007; Ludman et al., 2013), and
6 studies were systematic reviews (Bradford et al., 2013; Kelly, Fenwick, et al., 2014; Siantz &
Aranda, 2014; Tosh et al., 2011; van Hasselt et al., 2013; Whiteman et al., 2016). Excluded
from this review were studies that focused on diet and nutrition because these studies were
included in the weight loss interventions theme. Studies that used self-management strategies to
address psychiatric symptoms, but not physical health, were also excluded.
A variety of interventions were identified. Many used an adapted version of the Stanford
Chronic Disease Self-Management model (Battersby et al., 2013; Druss et al., 2010; Goldberg,
Dickerson, et al., 2013; Siantz & Aranda, 2014). Peer support and coaching was another com-
mon approach (Kelly, Fenwick, et al., 2014; Kelly, Fulginiti, et al., 2014).
Statistically significant evidence supports the use of physical health interventions to increase
visits to primary care providers (Druss et al., 2010; Kelly, Fenwick, et al., 2014; Kelly, Fulginiti,
et al., 2014; Tosh et al., 2011), to increase positive attitudes toward self-management (Druss
et al., 2010; Goldberg, Dickerson, et al., 2013; Ludman et al., 2013; Siantz & Aranda, 2014; van
Hasselt et al., 2013; Whiteman et al., 2016), and to increase self-reported healthy lifestyle behav-
iors (Chafetz et al., 2008; Druss et al., 2010; Goldberg, Dickerson, et al., 2013; Kelly, Fenwick,
et al., 2014; Ludman et al., 2013; Siantz & Aranda, 2014). For example, such interventions have
been related to reduced drug use, increased visits to a primary care doctor, and better medication
adherence. There also is evidence that physical health interventions demonstrate statistical signifi-
cance to reduce substance dependence (Battersby et al., 2013) and hospitalization (Bartels et al.,
2014b) and increase participation in health screenings and immunizations (Bradford et al., 2013).
23
Few studies included measures of physical health as an outcome (e.g., blood pressure, blood
glucose). However, 2 studies found a significant decrease in pain with an intervention that used
peer coaches to help participants connect to primary and specialty care services (Kelly, Fenwick,
et al., 2014; Kelly, Fulginiti, et al., 2014). One study conducted by occupational therapists found
a significant decrease in anxiety after participants received an intervention targeting the adop-
tion of healthy lifestyle behaviors such as review of positive and negative dietary patterns, exer-
cise, and substance use with monitoring of positive behavioral changes (Lambert et al., 2007).
Relaxation Interventions
Four systematic reviews and 12 RCTs provide strong evidence to support interventions to
promote relaxation. Four types of relaxation interventions were studied: (1) yoga, (2) progres-
sive muscle relaxation, (3) meditation, and (4) tai chi. Yoga was studied the most, in 3 system-
atic reviews (Balasubramaniam et al., 2013; Cramer et al., 2013; Vancampfort, Vansteelandt,
et al., 2012) and 7 RCTs (Behere et al., 2011; Ikai et al., 2013, 2014; Sarubin et al., 2014;
Vancampfort, De Hert, Knapen, Wampers, et al., 2011; Varambally et al., 2013; Visceglia &
Lewis, 2011). Progressive muscle relaxation was studied in 1 systematic review (Vancampfort
et al., 2013) and 2 RCTs (Chen et al., 2009; Vancampfort, De Hert, Knapen, Maurissen, et al.,
2011). Two RCTs examined meditation (Chan et al., 2012a; Ly et al., 2014), and 1 RCT exam-
ined tai chi (Yeung et al., 2012).
Multiple studies found that yoga was statistically more effective than a control condition
in reducing psychiatric symptoms, such as the positive and negative symptoms of schizophre-
nia (Balasubramaniam et al., 2013; Behere et al., 2011; Cramer et al., 2013; Vancampfort,
Vansteelandt, et al., 2012; Visceglia & Lewis, 2011) and anxiety (Vancampfort, De Hert,
Knapen, Wampers, et al., 2011). Yoga was significantly more effective than a control condition
in improving sleep, QOL, and postural stability (Ikai et al., 2014) for participants living with
SMI. One study found a statistically significant improvement in QOL and well-being for care-
givers receiving yoga (Varambally et al., 2013). Another study of yoga, however, found no dif-
ference between the intervention and control groups in improved resilience among participants
living with schizophrenia (Ikai et al., 2013).
Mixed evidence indicates that yoga is effective in improving depression. One study found
no difference in depression between a yoga group and a control group (Sarubin et al., 2014). In
contrast, a systematic review indicated that yoga improves depression in participants living with
schizophrenia (Balasubramaniam et al., 2013).
Additional studies reviewed relaxation techniques other than yoga as interventions.
Meditation had statistical significance as more effective than no intervention in improving
depression and sleep among participants living with depression (Chan et al., 2012a), but it was
not more effective in improving depression than behavioral activation (Ly et al., 2014).
Two RCTs demonstrated statistical significance for progressive muscle relaxation being effective
in reducing anxiety among participants living with SMI (Chen et al., 2009; Vancampfort, De Hert,
Knapen, Maurissen, et al., 2011). A systematic review supported progressive muscle relaxation
to reduce anxiety and psychological distress and to improve subjective well-being (Vancampfort
et al., 2013); however, progressive muscle relaxation was found to be less effective for reducing
positive symptoms (Chen et al., 2009). Finally, a study examining tai chi did not find differences
between the intervention and control groups in depression symptoms (Yeung et al., 2012).
Exercise Interventions
Of the four health and wellness themes, exercise was the most frequently researched. Strong evi-
dence from 34 studies supports exercise as an intervention, including 25 RCTs (Acil et al., 2008;
Battaglia et al., 2013; Beebe et al., 2010, 2013; Belvederi et al., 2015; Chalder et al., 2012;
Danielsson et al., 2014; Esquivel et al., 2008; Greer et al., 2015; Hoffman et al., 2011; Kerling
et al., 2015; Kerse et al., 2010; Krogh et al., 2012; Lee et al., 2014; Loh et al., 2016; Marzolini
et al., 2009; Merom et al., 2008; Pajonk et al., 2010; Pfaff et al., 2014; Rethorst et al., 2013;
Scheewe et al., 2013; Schuch et al., 2011; Silva et al., 2015; Trivedi et al., 2011; Wedekind et al.,
2010) and 9 systematic reviews (Farholm & Sørensen, 2016; Firth et al., 2015; Holley et al.,
2011; Jayakody et al., 2014; Pearsall et al., 2014; Rosenbaum et al., 2014; Silveira et al., 2013;
Stubbs et al., 2016; Vancampfort, Probst, et al., 2012).
24
Studies specific to subgroups included 8 RCTs and 3 systematic reviews devoted to people liv-
ing with schizophrenia, 10 RCTs and 1 systematic review devoted to people living with depression,
and 3 RCTs and 1 systematic review devoted to people with anxiety disorders. Most exercise pro-
grams focused on
• Some form of cardiovascular exercise (Acil et al., 2008; Belvederi et al., 2015; Chalder
et al., 2012; Danielsson et al., 2014; Esquivel et al., 2008; Hoffman et al., 2011; Kerling
et al., 2015; Krogh et al., 2012; Marzolini et al., 2009; Pajonk et al., 2010; Rethorst et al.,
2013; Scheewe et al., 2013; Schuch et al., 2011),
• Walking (Beebe et al., 2010, 2013; Kerse et al., 2010; Lee et al., 2014; Loh et al.,
2016; Merom et al., 2008; Pearsall et al., 2014; Silva et al., 2015; Trivedi et al., 2011;
Vancampfort, Probst, et al., 2012; Wedekind et al., 2010), or
• Participation in recreational activities (Battaglia et al., 2013).
Exercise provided several positive outcomes. One study found statistically significant
improvements in sleep for participants living with depression (Rethorst et al., 2013). Another
found statistically significant changes in hippocampal volume and improved memory for people
living with schizophrenia (Pajonk et al., 2010). Still another found a statistically significant
reduction in cognitive errors for people living with depression (Greer et al., 2015). Multiple stud-
ies of people living with schizophrenia found statistically significant differences favoring partici-
pants in an exercise group compared with control participants in reduction of both negative and
positive symptoms (Acil et al., 2008; Loh et al., 2016; Rosenbaum et al., 2014; Scheewe et al.,
2013; Silva et al., 2015). Three studies used some form of aerobic exercise (Acil et al., 2008; Loh
et al., 2016; Silva et al., 2015), and 1 study (Acil et al., 2008) combined aerobic exercise with
resistance training. Some studies also found a statistically significant reduction in anxiety (Holley
et al., 2011) and depression (Scheewe et al., 2013) and a statistically significant improvement in
QOL (Holley et al., 2011; Loh et al., 2016) for participants living with schizophrenia.
The studies that examined the benefits of exercise in reducing depressive symptoms among
people living with major depression had mixed results. Three RCTs (Danielsson et al., 2014;
Schuch et al., 2011; Trivedi et al., 2011) and 1 systematic review (Silveira et al., 2013) found
that exercise did statistically significantly reduce depressive symptoms, whereas 6 RCTs found
no difference between the exercise and control groups (Belvederi et al., 2015; Chalder et al.,
2012; Kerling et al., 2015; Kerse et al., 2010; Krogh et al., 2012; Pfaff et al., 2014).
Fewer studies examined anxiety disorders, including 1 systematic review (Jayakody et al.,
2014) and 3 RCTs (Esquivel et al., 2008; Merom et al., 2008; Wedekind et al., 2010). However,
consistent results indicate that exercise had a statistically significant effect in reducing stress and
anxiety. Surprisingly few studies examined fitness level, and those that did found little or no dif-
ference between the intervention and control groups (e.g., Belvederi et al., 2015). One system-
atic review found statistically significant improvement in maximum oxygen uptake (VO2 max),
the highest amount of oxygen a person can use during periods of maximal exercise intensity,
for people living with depression who participated in exercise (Stubbs et al., 2016). Two RCTs
found statistically significant improvements in walking distance for participants living with
schizophrenia (Lee et al., 2014; Marzolini et al., 2009), and 2 studies found a statistically signifi-
cant improvement in cardiovascular fitness for participants living with schizophrenia (Scheewe
et al., 2013) and depression (Danielsson et al., 2014).
Weight Loss Interventions

All weight loss intervention studies used lifestyle interventions that included a range of com-
ponents, such as exercise, educational sessions, motivational interviewing, mentor programs,
behavior therapy, and diet changes. Some similarities across instructional methods were found.
The instructional component of the interventions acknowledged the need to accommodate pos-
sible cognitive concerns common in the population (e.g., topics were broken down into smaller
components, key points were repeated). In addition, the interventions typically focused on
changing a few key behaviors (e.g., eating at least five servings daily of fruits and vegetables,
decreasing sugary drinks), although the targets varied across the interventions.
The most effective studies focused on specific behavioral change, such as specific dietary rec-
ommendations (C. A. Green et al., 2014, 2015; Mauri et al., 2008), or included content related
to both nutrition and physical activity in conjunction with combined group and individual
25
sessions (Bartels et al., 2013, 2015; Daumit et al., 2013). Some studies also found improvements
in fitness levels as measured by walking speed (Bartels et al., 2013, 2015; Krogh et al., 2014;
Masa-Font et al., 2015).
The length of the interventions differed greatly, ranging from 12 weeks to 18 months. The
interventions were carried out either in group sessions or with a combined approach of group
and individual sessions. The sample sizes for the individual studies ranged from 15 to 291 par-
ticipants. The mean age range for the studies was 25.8 to 53.5 years, with most studies having a
mean age in the 40s. The gender of participants ranged from 18% to 71% male, with most stud-
ies having more female than male participants. The average change in weight for the interven-
tion groups ranged from –9.9 to +3.8 pounds.
Nineteen Level I studies provide strong evidence for the effectiveness of weight loss programs
for individuals living with SMI, including 2 systematic reviews (Bruins et al., 2014; Krogh et al.,
2014) and 17 RCTs (Attux et al., 2013; Bartels et al., 2013, 2015; Brown et al., 2014; Cordes
et al., 2014; Daumit et al., 2013; Forsberg et al., 2008; Goldberg, Reeves, et al., 2013; C. A.
Green et al., 2014, 2015; Iglesias-García et al., 2010; Masa-Font et al., 2015; Mauri et al., 2008;
Methapatara & Srisurapanont, 2011; Pagoto et al., 2013; Usher et al., 2013; Wu et al., 2008).
Seven studies found statistically significant differences between the intervention and con-
trol groups at one or more time points during the study (Bartels et al., 2015; Brown et al.,
2014; Daumit et al., 2013; C. A. Green et al., 2014, 2015; Mauri et al., 2008; Methapatara &
Srisurapanont, 2011). Brown et al. (2014) is the only known study that included an occupa-
tional therapist in the development of the intervention. Only 1 study (Goldberg, Reeves, et al.,
2013) did not result in mean weight loss for the intervention participants at one or more time
points.
Five studies measured weight loss at only one point in time (3, 6, or 12 months). Eight stud-
ies measured weight loss at two points in time (most commonly at 3 and 6 months or at 6 and
12 months), and 1 study measured weight loss at three points in time (1, 2, and 3 months). All
of the studies that measured weight loss at multiple time points reported weight loss early in
the intervention, with 4 studies finding increasingly greater weight loss over time (Attux et al.,
2013; Bartels et al., 2015; Daumit et al., 2013; C. A. Green et al., 2015). Although these studies
yielded significant weight loss results, clinical weight loss ranged from approximately 1 pound to
9 pounds, with an approximate average loss of 4 pounds. Studies did not report starting weights
for comparison. Three studies reported finding initial weight loss but some weight gain over
time (Bartels et al., 2013; Brown et al., 2014; Iglesias-García et al., 2010). Eight studies did not
find a difference between the weight loss intervention and control groups (Cordes et al., 2014;
Forsberg et al., 2008; Goldberg, Reeves, et al., 2013; Iglesias-García et al., 2010; Krogh et al.,
2014; Masa-Font et al., 2015; Pagoto et al., 2013; Usher et al., 2013).
The study reporting only body mass index (BMI) and not weight loss did find a difference
between groups (Masa-Font et al., 2015). However, it was the control group that experienced
a greater change in BMI. The study comparing a lifestyle intervention to a lifestyle interven-
tion with behavior therapy found that both groups lost weight, with no significant difference
between the groups (Pagoto et al., 2013). The study examining prevention of weight gain did
not find a difference between groups (Cordes et al., 2014).
Several studies found benefits outside of weight loss for the intervention group. Three studies
found improvements in fitness levels (Bartels et al., 2013, 2015; Masa-Font et al., 2015), and 2
studies found better fasting glucose levels (Cordes et al., 2014; C. A. Green et al., 2015). Pagoto
et al. (2013) reported improvements in depression.
Two systematic reviews were included in the review. Bruins et al. (2014) included a meta-
analysis and found that weight loss interventions had a moderate long-term effect on weight loss
compared with control conditions (p = .02). This review also examined prevention of weight
gain programs and found a large effect (p = .0002). Krogh et al. (2014) focused exclusively on
exercise interventions and found little evidence of weight loss.
The systematic review of weight loss interventions also analyzed the outcome of weight loss
using a meta-analysis (Brown, Geiszler, Lewis, & Arbesman, 2018). The meta-analysis found
a statistically significant difference in overall weight loss between the intervention and control
groups; however, the amount of weight lost was relatively small. Although most participants in
26
the cited studies did not meet the criterion of loss of >5% of body weight for metabolic changes
to be expected (Franz et al., 2015), individuals are likely to receive other benefits from partici-
pating in a weight loss intervention. It is important to note that individual variability exists in
weight loss, and mean loss is not representative of every person. Furthermore, the goal of pre-
venting further weight gain has its own impact on health. In addition, the amount of weight loss
found in this review is consistent with weight loss studies for the general population.

Health and wellness interventions for individuals living with SMI should be based on evidence-
based practice at the intersection of the needs of the client population, practitioners’ clinical
expertise, and systematic review findings. The systematic review findings for physical health,
relaxation, exercise, and weight loss interventions all demonstrate strong evidence for clinical
practice. Occupational participation and engagement for community-dwelling individuals living
with SMI can be enabled by occupational therapy, which provides distinct value in the array of
intervention services offered by health care professionals.
All occupational therapy intervention approaches for health and wellness need to be informed
by principles of primary and secondary prevention (AOTA, 2013a). Efforts to facilitate improved
function and QOL for individuals living with SMI need to include preventing or reducing physi-
cal diseases and conditions and limiting the effects of secondary conditions. Education in healthy
lifestyle behaviors and ongoing support to improve and maintain healthy behaviors have been
demonstrated to improve the overall health of individuals living with SMI. Although the lifestyle
strategies of physical health, relaxation, exercise, and weight loss were investigated as separate
approaches, occupational therapy practitioners may provide combined interventions to yield
satisfactory occupational participation. Although combinations of interventions may help indi-
viduals living with SMI achieve better overall health, each strategy can be viewed as adding or
expanding interests and habits in the repertoire of occupational activities of these individuals.
Assessment and accommodation of cognitive capacities are critical in developing effec-
tive interventions for health and wellness. Instructional components for improving physical
health management, relaxation, exercise, or weight loss need to be analyzed for their level of
environmental or activity demands. Presenting information for healthy lifestyles at cognitive
levels that match client functioning will lead to greater effectiveness in promoting individual
learning of performance skills and EF needed for life management of healthy routines and
habits.
Interventions with focused or specific target behaviors and repetitive approaches facilitate
more effective lifestyle changes. Interventions that use active learning, homework, and indi-
vidualized goal setting in conjunction with supportive environments (social and physical) are
most effective for individuals living with SMI. Specific physical health goals (e.g., reducing
blood pressure, reducing glucose levels) may result in measurable changes in physical health
outcomes (Brown & Engelhardt, 2018). Specific skill training is needed in all activities support-
ing physical health management, relaxation, exercise, and weight loss. Occupational therapy
practitioners should address instructional components of skill training needed to perform indi-
vidually selected tasks, such as yoga or cooking, to support these health and wellness catego-
ries. Facilitating achievement and maintenance of behaviors and habits of health and wellness
requires an understanding of the support needed for behavioral change.
When addressing health and wellness, occupational therapy practitioners need to consider
life management behaviors. Practitioners should consider implementing physical health self-
management programs targeted at developing positive attitudes toward healthy lifestyle behav-
iors and use of primary care services (Brown & Engelhardt, 2018). Although more research is
needed to support these programs’ effectiveness in improving physical health, the goal should be
to help clients adopt and maintain healthy routines and habits. Occupational therapists’ exper-
tise in skill training and habit formation makes them well suited for developing new physical
health interventions and modifying existing programs (Brown & Engelhardt, 2018). Similarly,
occupational therapists should consider helping clients integrate wellness practices, such as yoga
and progressive muscle relaxation, into their daily routines (Brown & Toenies, 2018).
27
Occupational therapy practitioners are well suited to develop and lead exercise programs
toward the goal of helping clients living with SMI adopt exercise as a pattern of healthy routine
(Brown, Ali, & Lund, 2018). Weight loss programs should include content related to both nutri-
tion and physical activity (e.g., exercise components with specific dietary recommendations), at
least weekly sessions, and a combined group and individual approach. Realistic goals and ongo-
ing intervention and support will help clients continue to meet weight loss goals and maintain
weight loss over time (Brown, Geiszler, Lewis, & Arbesman, 2018).
To implement evidence from the systematic reviews for the four health and wellness interven-
tion categories, occupational therapy practitioners should consider supporting ADLs or IADLs.
For example, integral to weight loss are the IADLs of cooking, eating, and shopping. Beyond
information acquisition, client adaptation of new lifestyles requires development of habits and
rituals to support improved health and wellness occupations. Health management, including
medical appointments, medication adherence, and reduction of substance use, requires a com-
bination of cognitive acquisition of information and task and time management skills. Initial
learning and development of habits of relaxation are essential to enhancing healthy lifestyle
behaviors. Similarly, exercise and weight loss interventions require matching environmental and
activity demands to the performance capacities of clients.
Although the goal of occupational therapy interventions is not psychiatric symptom reduc-
tion, a secondary effect of symptom reduction is clients’ increased ability to engage in healthy
lifestyle behaviors and satisfactory occupational participation. The strong evidence for health
and wellness interventions supports reducing the direct impact of psychiatric symptoms for
clients living with schizophrenia, major depression, and bipolar disorder. The evidence also sup-
ports yoga to reduce positive and negative symptoms among people living with schizophrenia,
whereas the evidence supporting yoga to improve depression is less clear (Brown & Toenies,
2018). Progressive muscle relaxation is supported to reduce anxiety, yet meditation and tai chi
are less supported (Brown & Toenies, 2018). Exercise seems to be particularly useful in reducing
negative and positive symptoms of schizophrenia and anxiety, whereas support for exercise to
reduce depressive symptoms is less clear (Brown, Ali, & Lund, 2018).
The scope of practice defining occupational therapy interventions to promote health and
wellness encompasses the overall occupational engagement and participation of individuals
living with SMI. Adoption of healthy lifestyles can have an immediate impact by improving
physical health as well as a broad impact by enabling satisfactory participation in all areas of
occupation. For example, evidence for relaxation interventions supports subjective reports of
improved sleep, QOL, and overall well-being, and evidence supports the use of yoga to improve
QOL, sleep, and postural stability (Brown & Toenies, 2018). Occupational therapy practitioners
need to be at the forefront in demonstrating that individuals living with SMI have the capacity
to improve their QOL, health, and wellness through engagement in satisfying occupations.
28
Support Early Intervention
for Adolescents and Young
Adults Living With SMI
E vidence is increasing that the transition from adolescence to young adulthood is the period
in which the majority of SMIs have their onset (McGorry, 2011). Early detection and rapid
intervention may reduce the impact of SMI and may even delay or prevent transition to SMI.
Early detection can reduce the risk of death by suicide or a lifetime of disability characterized by
unemployment, incomplete education, social isolation, and significant symptoms that interfere
with daily living (Gonzalez et al., 2015; McGorry, 2011).
SMI costs the U.S. government substantial amounts of money for Medicaid subsidies and
other benefits (Gonzalez et al., 2015). Early intervention services (EIS), especially for individu-
als experiencing the early signs or first episode of psychosis, have been shown to be effective in
reducing the impact of SMI through early detection, targeted interventions, and easy access to
care (Bird et al., 2010; Gonzalez et al., 2015).
This chapter summarizes the evidence for the effectiveness of occupational therapy interven-
tions for individuals experiencing early psychosis. Thirty articles were included in the systematic
review (Read et al., 2018). Twenty-two articles provide Level I evidence, 6 provide Level II evi-
dence, and 2 provide Level III evidence (Table 6.1).
Interventions
Critical appraisal of the evidence revealed four themes: (1) cognitive remediation (CR) interven-
tions, (2) cognitive–behavioral therapy (CBT), (3) supported employment/supported education
(SE/SE), and (4) family psychoeducation (FPE). CRT consists of behavioral training in prac-
tice drills or training in compensatory strategies to improve cognitive functioning, including
Table 6.1. Levels of Evidence for Interventions to Support Early Intervention for Adolescents
and Young Adults Living With SMI
I RCTs 6
II Two groups, nonrandomized studies (cohort, case-control) 2

pretest–posttest)

Total 30
29
Table 6.2. Levels of Evidence for Interventions to Support Early Intervention for Adolescents
and Young Adults Living With SMI, by Theme
Level of Cognitive Cognitive– Supported

Evidence and Remediation Behavioral Employment/ Family
Design Training Therapy Supported Education Psychoeducation
Level I systematic 0 1 1 0
reviews and
meta-analyses
Level I RCTs 6 8 2 4
Level II 1 0 2 3
Level III 0 0 1 1
Total 7 9 6 8
attention, memory, EF, social cognition, and metacognition, through computer training or
manual exercises with therapist facilitation (Lee et al., 2013). CBT typically consists of struc-
tured education sessions over a time-limited period with a focus on cognitive restructuring and
problem-solving skill practice (Brent et al., 2015).
Supported employment services are based primarily on the IPS model, which structures ser-
vices to include eight principles: “consumer choice, focus on competitive employment, integra-
tion of mental health and employment services, attention to patient preferences, work incentives
planning, rapid job search, systematic job development, and individualised job supports” (Bond,
Drake, & Luciano, 2015, p. 448). IPS has been expanded to include supported education pro-
grams. FPS addresses psychoeducation and structured training in communication enhancement
skills and problem-solving skills for family members (O’Brien et al., 2014). Table 6.2 presents
the number of studies and levels of evidence for each of the four themes.
Cognitive Remediation Interventions

Six Level I RCTs and 1 Level II study examined the effectiveness of CR interventions in improv-
ing and maintaining performance in occupations for persons at high risk for or in the early
stages of SMI. CR interventions focus on enhancing working memory, attention, direction fol-
lowing, and EF. Strong evidence was found for using CR in early intervention for psychosis to
improve cognition, self-esteem, and social occupation. All 6 Level I CR studies reported statisti-
cally significant improvements at the termination of intervention in specific targeted cognitive
areas and social and occupational functioning using computer-based cognitive training activities
(Holzer et al., 2014; Lee et al., 2013; Loewy et al., 2016; Mendella et al., 2015; Østergaard
Christensen et al., 2014) or paper-and-pencil activities (Puig et al., 2014).
Østergaard Christensen and colleagues (2014) found that CR statistically significantly
improved participants’ verbal learning immediately and at 12-month follow-up. In addition,
working memory was significantly improved at 12 months. The Level II pretest–posttest study
showed statistically significant improvements in cognition and overall functioning after computer-
ized cognitive training for participants with clinical high risk (CHR) for psychosis (Rauchensteiner
et al., 2011). However, Puig et al. (2014) found that at 3 months the significant functional gains
were not statistically significantly maintained, limiting the evidence for the duration of effect.
Cognitive–Behavioral Therapy
Nine Level I studies (8 RCTs, 1 systematic review) explored the effectiveness of CBT in treat-
ing cognitive dysfunction and symptoms to improve overall functioning. The studies focused
on youth living with CHR for psychosis, FEP, or depression. CBT intervention targets cognitive
distortions or distorted thinking and enables individuals to use enhanced thinking strategies or
cognitive restructuring to implement improved behavioral actions.
30
E VI D EN C E F O R I N TERVEN TI O N S to Su pport Ea rl y I ntervention
Clinical High Risk or First-Episode Psychosis. Strong evidence for the effectiveness of CBT in
improving functioning was found in 6 Level I studies. Hutton and Taylor’s (2014) meta-analysis
of 6 RCTs testing CBT versus TAU with nonmedicated youth at CHR for psychosis found strong
evidence for reduced risk of conversion to psychosis up to 24 months, with reduced symptoms
at 1-year follow-up. Conversion to psychosis leads to decreased occupational functioning (Bird
et al., 2010; Gonzalez et al., 2015). An RCT by Gleeson et al. (2013) found substantially lower
relapse rates and a significant delay in time to relapse for the CBT intervention group compared
with a control group, but these results were not sustained at 12-month follow-up. As with
conversion to psychosis, relapse leads to decreases in occupational functioning.
In an RCT, Jackson et al. (2008) found statistically significant more functional improve-
ment (as measured by the Social Occupational Functioning Scale; Saraswat et al., 2006) in the
CBT intervention group at the midway point compared with the control group, but neither
group maintained improvements over time. An RCT by Yung et al. (2011) examined the effects
of CBT with or without medication (two intervention cohorts) versus supportive therapy and
a control condition of follow-up assessment only. The CBT without medication, supportive
therapy, and control groups all had statistically significant gains in functioning as measured
by Global Assessment of Functioning (GAF) and Quality of Life Scale, whereas the CBT plus
medication group did not. Three RCTs (Addington et al., 2011; Bechdolf et al., 2007; Jackson
et al., 2008) found no statistically significant differences between CBT and control groups.
Depression. Three Level I RCTs evaluating CBT’s effectiveness with youth living with
depression demonstrated mixed results, especially for sustained improvements. Depressive
symptoms have a negative impact on occupational functioning. Brent et al. (2015) tested a
time-limited cognitive restructuring intervention with 6-month booster sessions for youth with
subsyndromal depressive symptoms. Functional outcomes were reported only at the 6-year mark
and showed no differences between groups. Clarke et al. (2001) found statistically significant
increases in GAF scores for the intervention group; the intervention included education about
the treatment sessions for parents. At 2-year follow-up, however, treatment effects were not
sustained. Stice et al. (2008) tested three different interventions against a control condition
and found that CBT significantly reduced depressive symptoms compared with the other two
interventions and the control condition.
Supported Employment/Supported Education

Strong evidence was found in 3 Level I studies, 2 Level II studies, and 1 Level III study examining
SE/SE with individuals living with CHR for psychosis or FEP. Two Level I RCTs and 1 systematic
review examined the effectiveness of IPS with FEP youth. Both RCTs demonstrated strong evi-
dence that IPS offered in addition to TAU results in significantly better competitive employment
and education outcomes than TAU alone (Baksheev et al., 2012; Killackey et al., 2008).
The systematic review examined 28 studies with or without vocational assistance in EIS
and found strong evidence that supported employment services increased employment rates of
participants (Bond, Drake, & Luciano, 2015). However, the wide variety of measures used in
studies without vocational assistance makes it difficult to draw conclusions on employment and
educational outcomes. In some studies, supported employment programs included supported
education interventions within the overall supported employment intervention model, so these
programs cannot be viewed as separate interventions.
Limited evidence was demonstrated in 2 Level II studies providing vocational assistance.
Dudley et al. (2014) used a naturalistic comparison design with two matched groups and found
that participants in IPS offered by a vocational specialist in an EIS program showed a statistically
significant increase in employment during the assistance phase. However, employment declined
during the 6-month follow-up phase once support ended. In a naturalistic cohort study, compre-
hensive vocational assistance services led by occupational therapists resulted in statistically signif-
icantly better vocational status outcomes compared with a control condition (Major et al., 2010).
Finally, a Level III pretest–posttest study using IPS plus education in an EIS program demon-
strated limited evidence that vocational assistance was beneficial. Employment rates improved
during the first 6 months of a 2-year period of support but were not sustained through the
remaining 18 months. The attrition rate was high during the study (Rinaldi et al., 2010).
31
Family Psychoeducation Interventions

Eight studies—4 Level I RCTs, 3 Level II studies, and 1 Level III study—that addressed fam-
ily interventions and psychoeducation provide moderate evidence that these interventions can
reduce symptoms and improve functioning. The 3 Level II studies and 1 Level III study provide
moderate evidence supporting FPE to improve functioning and reduce symptoms. Granö et al.
(2016) matched two groups and found that FPE resulted in statistically significant improvement
in functioning (20% vs. 6%). In a multisite study, Harder et al. (2014) compared standard treat-
ment plus a manualized FPE program over 3 years to standard treatment and found statistically
significantly improved social functioning in the intervention group. However, the results were
not sustained at 5-year follow-up (Harder et al., 2014). A risk-based allocation study found that
structured FPE delivered in a group format along with other program interventions statistically
significantly improved functioning (McFarlane et al., 2015). A Level III study demonstrated that
family-oriented meetings held in natural surroundings for youth at CHR for psychosis statisti-
cally significant increased overall functioning (school and work) and QOL (Granö et al., 2009).
Four Level I RCTs examining FPE with youth living with CHR for psychosis or FEP provide
strong evidence that FPE reduces symptoms and improves functioning. Calvo et al. (2014) found
that group FPE for FEP youth and their families resulted in statistically significantly fewer emer-
gency room visits and improved negative symptoms, along with the clinical improvements of
fewer hospitalizations and renewed interest in recreation, at 6-month follow-up compared with
a control condition. Both the intervention and control groups showed improved functioning. At
2-year follow-up, the effects of group FPE on FEP youth were sustained, and the FPE group had
significantly fewer emergency room visits (13% vs. 50%; Calvo et al., 2015).
In a study examining the effects of FPE on communication and problem solving in individual
family sessions for youth living with CHR for psychosis or FEP over 6 months, Miklowitz
and colleagues (2014) found statistically significant improvements in social and role function-
ing at 6 months for the intervention group. Finally, O’Brien et al. (2014) studied the effects of
FPE on family communication and learning of problem-solving skills. The FPE group received
structured, individual family sessions for 6 months, and the control group received EIS without
FPE. The FPE group showed significant improvement in family communication during family
problem-solving interactions compared with the control group.

Early intervention for individuals at risk for developing SMI should be based on evidence-based
practice at the intersection of the needs of individual clients, practitioners’ clinical expertise, and
systematic review findings. The early intervention systematic review findings for CRT, CBT,
SE/SE, and FPE interventions provide strong evidence for clinical practice. Occupational therapy
practitioners can provide early interventions for individuals at risk for early psychosis to help
them enhance and maintain occupational performance and community participation. The strong
evidence supporting CRT indicates that practitioners should engage clients in computerized drills
or manual exercises. Use of CRT strategies needs to be embedded in client-relevant occupations
to enhance occupational performance (AOTA, 2018). These strategies are most effective when
combined with intervention sessions that apply targeted cognitive areas of attention, memory,
and EF to daily living. Discussion about using improved cognition in everyday occupations can
provide clients with strategies for maintaining or improving social interactions in addition to
school or work performance. Facilitating repeated practice of cognitive strategies in these areas
by clients can also enable successful performance in ADLs, IADLs, and leisure activities.
For youth living with CHR or FEP, the risk of conversion to psychosis is great. Strong evi-
dence supports interventions incorporating CBT to reduce or delay conversion to psychosis.
Interventions that use occupation-focused strategies to facilitate individuals’ ability to recog-
nize ineffective thinking strategies and implement cognitive restructuring can help eliminate or
reduce functional declines. Although the studies in this review were not carried out by occu-
pational therapy practitioners, the evidence identifies the critical role of emphasis on cognitive
restructuring during actual occupational performance in leading to prolonged functional out-
comes. Thus, occupational therapy practitioners should enable individuals to practice effective
problem-solving strategies within daily tasks to promote greater functional performance.
32
E VI D EN C E F O R I N TERVEN TI O N S to Su pport Ea rl y I ntervention
Supported employment using the IPS model has a thorough evidence base supporting indi-
vidual participation in competitive employment for adults. In youth at risk for psychosis, the
implementation of supported employment programs at typical developmental times can be cru-
cial in aiding entry into the adult workforce. Occupational therapy practitioners can implement
supported employment programs or complement other vocational professionals in providing job
coaching and interventions aimed at promoting ADL and IADL performance. Activity, occupa-
tional, and environmental analyses for work performance are critical for occupational therapy
practitioners to incorporate into interventions to enable individuals to participate in work
occupations.
In FPE, occupational therapy practitioners assist the entire family to understand and support
the individual at risk to improve or maintain occupational functioning. Enhancing family com-
munication strategies enables identification of and solutions to challenges in daily performance,
leading to improved QOL for the individual and the entire family.
Evidence supporting EIS for individuals at risk for psychosis highlights a crucial role for
occupational therapy practitioners. The acquisition or maintenance of functioning to support
community engagement needs to occur through the doing of daily activities, the most significant
domain of occupational therapy.
33
Reduce Internalized Stigma
A growing number of people living with SMI experience elevated internalized stigma (Roe
et al., 2014; Yanos et al., 2012). Internalized stigma (also called self-stigmatization or self-
stigma) is a process in which the individual living with mental illness adopts and internalizes
the stigmatizing opinions of society, such as the idea that he or she is dangerous or incompetent.
Higher levels of internalized stigma are believed to have a negative impact on self-esteem, social
relationships, and functional outcomes among people living with SMI. Embracing negative ste-
reotypes about mental illness generates negative implicit beliefs, which affect QOL and often
lead to self-fulfilling prophecies of failure (Lysaker et al., 2012).
Interventions that reduce internalized stigma have the potential to enhance recovery and com-
munity participation. Occupational therapy practitioners are ideally suited to provide education
and support that promotes skill building to enhance community participation for people living
with SMI.
Internalized stigma is a growing target for research, but the current state of science on this
topic is limited. Stigma seriously affects the occupational performance of adults living with SMI,
so occupational therapy practitioners must seek guidance for best practice in this area. Because
of the importance of this topic, a focused question on interventions to reduce internalized stigma
and self-stigma for people living with SMI was included in this systematic review. The search
produced evidence from 14 Level I studies, 3 Level II studies, and 3 Level III studies that spe-
cifically addresses interventions for individuals experiencing self-stigma or internalized stigma
(Swarbrick, 2018). Table 7.1 lists the levels of evidence for the included articles.
Interventions
The systematic review of the evidence for reducing internalized stigma revealed six themes for
intervention: (1) psychoeducation, (2) CBT, (3) SST, (4) Narrative Enhancement and Cognitive
Therapy (NECT), (5) group discussion, and (6) vocational rehabilitation. Table 7.2 presents the
number of articles found at each level of evidence for these themes (Swarbrick, 2018).
Table 7.1. Levels of Evidence for Interventions to Reduce Internalized Stigma
I RCTs 12
II Two groups, nonrandomized studies (cohort, 3

case-control)
III One group, nonrandomized studies (before 3

and after, pretest–posttest)
Total 20
34
E vi d en c e f o r In terven ti o n s to Red u c e In tern a l i zed Stigma
Table 7.2. Levels of Evidence for Internalized Stigma Interventions, by Theme
Narrative
Level of Cognitive– Enhancement
Evidence Psycho Behavioral Social Skills and Cognitive Group Vocational
and Design education Therapy Training Therapy Discussion Rehabilitation
Level I systematic 2 0 0 0 0 0
reviews and
meta-analyses
Level I RCTs 5 1 1 1 3 0
Level II 0 0 0 1 1 1
Level III 2 1 1 0 0 0
Total 9 2 2 2 4 1
Psychoeducation Interventions
Two Level I systematic reviews, 5 Level I RCTs, and 2 Level III studies addressed interventions
using psychoeducation to reduce internalized stigma. In their systematic review, Mittal et al.
(2012) identified two modes of intervention for reducing self-stigma: (1) those targeting the stig-
matizing beliefs and attitudes held by the individual and (2) those directed toward development
of coping skills to improve self-esteem, empowerment, and help-seeking behavior. The latter
approach is being used more often by stigma experts (Mittal et al., 2012). Tsang et al. (2016)
reported in the other systematic review that most internalized stigma reduction programs they
reviewed appeared to be effective, but they found psychoeducation most promising. Both system-
atic reviews found small to moderate effects across the stigma reduction programs they reviewed.
The RCTs that included psychoeducation showed mixed results and therefore present moder-
ate evidence for effectiveness. McCay et al. (2007) examined group psychoeducation provided
in 90-minute sessions over 12 weeks and did not find significant differences in self-stigma. They
did, however, find significant differences on measures of engulfment, hope, and QOL, all identi-
fied as factors contributing to developing self-stigma.
Aho-Mustonen and colleagues (2011) conducted an RCT of psychoeducation with 39
individuals living with schizophrenia in a high-security forensic hospital. Perceived Stigma
Questionnaire (Link et al., 1989) scores decreased during the intervention phase for both
groups, but much more for the control group, which seemed to be a negative treatment effect
for group psychoeducation. However, the psychoeducation group showed significant increases in
global self-esteem postintervention and knowledge of schizophrenia at 3-month follow-up.
Sibitz et al. (2013) examined the impact on internalized stigma of a recovery-oriented day
treatment clinic in Germany that included psychoeducation and occupational therapy. This RCT
allocated 80 participants to treatment groups on the basis of mean waiting time to start inter-
vention, and significant improvements were noted in internalized stigma reduction, symptom
reduction, and QOL, with a medium effect size.
Silverman (2013) used a cluster-randomized single-session design to examine the effects of
music on self and experienced self among 78 participants on an acute care psychiatric unit. The
intervention group showed significant differences on stigma scale scores compared with the
wait-list control but no difference compared with the education-only control. Çuhadar and Çam
(2014) examined group psychoeducation delivered in seven 90-minute sessions and found a sig-
nificant reduction in self-stigma compared with TAU for patients living with bipolar disorder.
A Level III two-group nonrandomized study (Uchino et al., 2012) examined the impact of a psycho-
education program to reduce self-stigma for 56 people living with schizophrenia and schizoaffective
disorder in Japan. The results provide limited evidence that increasing knowledge about mental disor-
ders and treatment, particularly schizophrenia, might play an important role in reducing self-stigma.
35
Cognitive–Behavioral Therapy Interventions

Only limited evidence from 1 Level I RCT and 1 Level III study demonstrates that CBT can
reduce internalized stigma. In a Level I multisite study in England, Morrison et al. (2013) found
an overall reduction over 12–24 months in negative appraisal of unusual experiences in young
people at risk of psychosis, suggesting that this intervention is nonstigmatizing for this popula-
tion. However, no significant interaction by treatment arm and no other significant differences
were demonstrated.
Two Level III studies also investigated this topic. One was an open pilot study with 21 par-
ticipants conducted in the Netherlands that examined the impact of CBT on psychotic disorders
(Staring et al., 2013); its findings did not reach significance. Another Level III pretest–posttest
study of a peer education intervention to reduce internalized stigma among depressed older
adults resulted in a significant reduction in internalized stigma (Conner et al., 2015). However,
the study included only 19 participants. Participants had lower perceptions of public stigma
and reduced internalized stigma after working with a peer educator. They felt more optimistic
about the attitudes held about depression by society and, in particular, by members of their own
community.
Social Skills Training Interventions

Moderate evidence exists from Level I RCT and 1 Level III study that contained an SST ele-
ment. In the RCT, Fung et al. (2011) found improvements in self-esteem decrement, readiness
to change own problematic behaviors, and psychosocial treatment adherence compared with a
control group (a newspaper reading group); however, the improvements were not maintained
at 6-month follow-up. Lucksted et al. (2011) used a single-group pretest–posttest design that
incorporated SST with group support and problem solving and found significant improvements
in internalized stigma reduction, overall well-being, self-empowerment, basic functioning, and
advocacy.
Narrative Enhancement and Cognitive Therapy Interventions

Two NECT studies provide mixed evidence. A Level I RCT (Yanos et al., 2012) found no
significant differences between NECT and TAU groups at follow-up. A Level II study using a
case-control nonrandomized concurrent control condition showed a significant change in self-
stigma for the treatment group (Roe et al., 2014). There were also significant improvements
in reported QOL and dispositional hope. Both NECT studies offered 20 sessions for up to 6
months.
Group Discussion Interventions

Four studies—3 Level I RCTs and 1 Level III study—used a group discussion intervention and
provide moderate evidence because of mixed results. An RCT comparing a program called
PhotoVoice to TAU found that participation in PhotoVoice was associated with significantly
reduced self-stigma and a greater increase in sense of community activism (Russinova et al.,
2014). Two RCTs (Corrigan et al., 2015; Rüsch et al., 2014) examined the Coming Out Proud
program; only Corrigan et al. (2015) showed a significant effect, compared with a wait-list con-
trol, on reduced self-stigma and improved stigma stress appraisals.
Lucksted et al. (2011) used a single-group pretest–posttest design to assess a group discussion
intervention that included sharing personal experiences and teaching and practicing skills. They
found significant improvements in internalized stigma reduction, overall well-being, and social
support received.
Vocational Rehabilitation Interventions

One Level II study by Lysaker et al. (2012) provides limited evidence to support the effectiveness
of a VR intervention to reduce internalized stigma. Participants in this quasi-experimental study
showed a statistically significant reduction in overall stigma and a significant effect for emo-
tional discomfort.
36
E vi d en c e f o r In terven ti o n s to Red u c e In tern a l i zed Stigma

Because of internalized stigma, many people living with SMI lose opportunities for full par-
ticipation in a community of their choice where they can make a meaningful contribution.
Although internalized stigma is clearly an important issue affecting community participation,
only a limited amount of evidence was available for this review of interventions to address
internalized stigma among people living with SMI, and the strength of that evidence is varied.
Interventions that used psychoeducation to address stigma-related elements such as self-esteem,
engulfment, QOL, and hope show the most beneficial effects in reducing internalized stigma.
Studies of NECT, CBT, and SST, however, provide only limited evidence of statistically signifi-
cant improvement in reducing internalized stigma.
The results of this systematic review must move occupational therapy practitioners to con-
sider that to promote maximal occupational performance for adults living with SMI, decreasing
internalized stigma is critical, both for people living with SMI and as a benefit for society. Given
that the identified targets for intervention around internalized stigma—self-esteem, engulfment,
QOL, and hope—fall within the purview of occupational therapy practice, practitioners are in
an ideal position to develop and research occupation-based interventions. Much opportunity
exists for occupational therapists to design and test interventions that address internalized
stigma to enhance participation and functioning among people living with SMI.
37
8. Implications of the Evidence
for Occupational Therapy
Practice, Education, and
Research
Implications for Occupational Therapy Practice

The systematic review of the literature included in this Practice Guideline on effective interven-
tions for adults living with SMI provides current evidence to inform clinical decision making in
occupational therapy practice and community-based services for this population. Evidence-based
practice involves the use of the best available research in combination with practice experience
and consideration of the unique values and preferences of the client within the context of service
provision. It guides clinical reasoning, justifies services, and promotes the best client outcomes.
Effective interventions enable clients to achieve full occupational participation and QOL.
Results of the systematic review support occupational therapy practitioners in integrating the
recommendations in this chapter into routine practice.
Interventions to Promote ADLs and IADLs, Rest and Sleep, Leisure, and Social
Participation
• H
olistic client-centered interventions should use occupation-based, cognition-based, skills-
based, and psychoeducation methods as a routine part of interventions to improve ADLs
and IADLs, rest and sleep, leisure, social participation, and QOL.
• Occupation-based programs provided individually or in group settings can improve occu-
pational performance and health outcomes and should include family or caregivers when
possible.
• Home-based intervention or intervention in natural settings should be considered.
• The building of daily routines and the sustainability of occupations should be considered
to improve QOL.
Interventions to Support Employment and Education

• O ccupational therapy practitioners should be integral members of teams providing IPS
services, which focus first on placing the client in a work setting and then on training the
client for the job, rather than the reverse. IPS also addresses nonvocational goals such as
developing social connections and enhancing community participation.
• CRT should be used to benefit clients seeking to begin working or to reenter the work-
force to facilitate full engagement in the worker role and to increase success in gaining and
sustaining employment.
• Occupational therapy practitioners should advocate for the establishment and funding of
more IPS and supported education programs to provide greater access to these services for
adults living with SMI.
Interventions to Promote Health and Wellness

• O
ccupational therapy practitioners should consider implementing self-management pro-
grams to address physical health concerns and promote positive attitudes toward increas-
ing healthy lifestyle behaviors and use of primary care services.
38
Imp l i c a t i ons o f t he E v i de nc e f o r O c c u pa tio n a l Th era py Pra c tic e, Ed u c a tio n , a n d Research
• S kill training and habit formation assist clients to adopt and maintain healthy routines
and habits, including participation in yoga, progressive muscle relaxation, and exercise.
• Health and wellness interventions should include active learning, homework, and individu-
alized goal setting and should target specific physical health goals (e.g., reducing blood pres-
sure, reducing glucose levels, losing weight, improving nutrition, increasing physical activity)
through a combined approach of group and individual sessions with ongoing support.
• Occupational therapy practitioners should approach weight loss realistically, acknowledg-
ing variability in the amount of weight loss among individuals.
• Common cognitive impairments in people living with SMI should be considered when pro-
viding instruction on physical health, relaxation, exercise, and weight loss interventions.
Interventions to Support Early Intervention

• O ccupational therapy practitioners should implement CRT strategies combined with
occupation-based interventions to enhance cognition and overall functioning for individu-
als at risk of developing depression or psychosis or in the early stages of SMI.
• CBT interventions focused on occupational performance should be offered in a group for-
mat, which provides more positive outcomes than an individual format.
• Occupational therapy practitioners should consider adding vocational services, such as
IPS, to promote positive outcomes in competitive employment and academics.
• Practitioners should seek out opportunities to cofacilitate FPE groups promoting social
and occupational functioning, engagement in meaningful activities, and task analysis.
Interventions to Reduce Internalized Stigma

• O
ccupational therapy practitioners should provide psychoeducational interventions for
adults living with SMI to reduce internalized stigma, promote opportunities for full partic-
ipation, and enable them to make meaningful contributions in their community of choice.
General Implications for Practice

• E vidence-based methods related to client needs should be used when providing interven-
tions to people living with SMI.
• Occupational therapy practitioners should persist in advocating for their clients’ needs in
all communities, agencies, and health care and legislative policies.
• Occupational therapy practitioners are essential team members for developing comprehen-
sive, client-centered programming for individuals living with SMI.
• Practitioners can support engagement in recovery and wellness by facilitating occupational per-
formance for people living with SMI in inpatient, outpatient, and community-based settings.
Implications for Occupational Therapy Education

The findings of the systematic review of interventions within the scope of occupational therapy
for adults living with SMI have implications for both occupational therapist and occupational
therapy assistant programs of study. On the basis of these findings, occupational therapy educa-
tors are encouraged to include the following components in educational curricula:
• Prepare students for evidence-based practice by providing them with the skills to locate
research literature and evidence-based resources, appraise and synthesize research litera-
ture to answer clinical questions, and integrate evidence into practice, using the best avail-
able evidence to inform the selection of appropriate evaluations and interventions and the
comprehensive clinical reasoning process.
• Train students to incorporate client-centered, goal-directed, occupation-centered, evidence-
based interventions as part of a comprehensive clinical reasoning process.
• Emphasize the need to gather comprehensive information about the client when develop-
ing the occupational profile (AOTA, 2017a).
• Provide students with opportunities to work with clients living with mental health challenges
during clinical training programs so that students can gain experience with clinician–client
interactions, development of client-centered intervention goals and plans, and clinical skills.
39
• I nclude foundational knowledge about mental health conditions, their impact on occupa-
tional participation, and secondary deficits and impairments.
• Teach students about the implications of occupational performance impairments, in addi-
tion to secondary deficits in client factors (e.g., cognitive, sensory) that affect performance,
and the long-term outcomes of limited participation and occupational engagement.
• Provide instruction in the multiple mental health intervention approaches to improving
participation outcomes (e.g., community and inpatient settings, delivery models, interven-
tion types).
• Familiarize students with psychometrically sound assessment tools and outcome measures
used in mental health practice and with research relevant to occupational therapy.
• Include course content about health and wellness (including prevention and self-
management principles) and self-efficacy.
• Emphasize the recovery model, peer supports, and approaches that address stigma
concerns.
• Describe interdisciplinary mental health approaches in which a role for occupational ther-
apy services exists, such as SE/SE models.
• Train students in applying CRT and CBT principles to occupational therapy interventions.
• Train students in program development and program evaluation methods applicable to the
diverse settings and intervention models for individuals living with SMI.
• Teach students to advocate for clients of occupational therapy services and to influence
policy development to promote best practices in addressing the unique needs of individu-
als living with SMI.
Implications for Occupational Therapy Research

Evidence from the systematic reviews provides support for some interventions that are within
the scope of occupational therapy practice for adults living with SMI. However, significant gaps
in the literature were revealed. Additional research is needed specific to occupational therapy for
adults living with SMI; this need presents opportunities for further development and advance-
ment of the evidence for the profession. On the basis of the systematic reviews, the following
areas of research are recommended to advance the current literature and to promote best prac-
tice with adults living with SMI:
• Function in relation to occupational performance or participation as defined by the
Occupational Therapy Practice Framework: Domain and Process (3rd ed.; AOTA, 2014)
as opposed to the general reports of function found in much research
• Standardized occupation-based outcome measures for all areas of occupation
• Longitudinal research addressing occupational performance or engagement outcomes to
determine whether occupational performance outcomes are sustained over time
• Occupation-based interventions supporting QOL as defined by clients living with SMI
• Occupational therapy interventions in supported employment programs to delineate the
crucial role of occupational therapy in providing these services
• Supported education models to determine effective strategies and programs for improving
occupational performance related to the student role, including cognitive and academic
function, social skills, and confidence
• Effect of occupational therapy interventions for health and wellness self-management
on the physical health of people living with SMI, including physical health, relaxation,
exercise, and weight loss
• Effective occupation-based interventions to address internalized stigma and promote
enhanced participation and functioning.
Conclusion
Many of the interventions presented in this review are part of an emerging body of research.
More research is needed to support occupation-based interventions for people living with SMI.
40
9. Clinical Recommendations for
Interventions for Adults Living
With Serious Mental Illness
C linical recommendations were developed after completion of the systematic reviews and
full analysis of the data collected. They are to be used to guide practice based on the find-
ings of the reviews. AOTA uses the grading methodology provided by the USPSTF (2013).
Table 9.1 provides the final grades for interventions described in this Practice Guideline; the
five letter grades can help clinicians understand at what level they can feel confident to use the
interventions.
Describing the strength of clinical recommendations is an important part of communicating
their efficacy to clinicians and other users. As always, research evidence needs to be considered
in conjunction with client needs and goals and sound clinical reasoning from a practitioner’s
experience. The scoring for clinical recommendations is as follows:
• A: There is strong evidence that occupational therapy practitioners should routinely pro-
vide the intervention to eligible clients. Good evidence was found that the intervention
improves important outcomes and that benefits substantially outweigh harm.
• B: There is moderate evidence that occupational therapy practitioners should routinely
provide the intervention to eligible clients. There is high certainty that the net benefit is
moderate, or there is moderate certainty that the net benefit is moderate to substantial.
• C: There is weak evidence that the intervention can improve outcomes. It is recommended
that the intervention be provided selectively on the basis of professional judgment and cli-
ent preferences. There is at least moderate certainty that the net benefit is small.
• I: There is insufficient evidence to determine whether occupational therapy practitioners
should be routinely providing the intervention. Evidence that the intervention is effective
is lacking, of poor quality, or conflicting, and the balance of benefits and harm cannot be
determined.
• D: It is recommended that occupational therapy practitioners not provide the intervention
to eligible clients. At least fair evidence was found that the intervention is ineffective or
that harm outweighs benefits.
Criteria for level of evidence and recommendations (A, B, C, I, D) are based on standard lan-
guage from the USPSTF (2013). Suggested recommendations are based on the available evidence
and content experts’ clinical expertise regarding the value of using such evidence
41
Table 9.1. Clinical Recommendations for Occupational Therapy Interventions for Adults Living With SMI
Category Interventions
ADLs and IADLs, rest • Individualized interventions in residential settings to improve ADL and IADL performance for people living with schizophre-
and sleep, leisure, and nia (A)
social participation • Illness Management and Recovery program to improve targeted functions of medication and illness management (A)
• Cognition-based interventions with a social skills or relationship component to improve social interactions, relationships,
and QOL (A)
• Exercise as a daily occupation, regardless of dosage, along with medication to improve sleep in clients living with non
remitted major depressive disorder (B)
• Manualized psychoeducational programs to improve ADLs, IADLs, relationships, and living skills (B)
• Education; role-playing; and social, communication, and assertiveness skills training to improve sexual activity safety (B)
• Tailored client-centered psychoeducation intervention to enhance social participation goals and social contacts (B)
• Year-long HOPES weekly skills training program to improve community living skills, health care use, social functioning, and
negative symptoms for older adults living with SMI (B)
• Cognition-based interventions of mindfulness practice, breathing, and CBT to improve sleep outcomes (B)
• SCIT program combined with social mentoring to improve social engagement outcomes (B)
• CAT program (home-based intervention using environmental supports) to improve grooming and hygiene (C)
• Animal-assisted therapy to improve social participation and engagement for people with schizophrenia (I)
• Technology use as part of IADL interventions for people living with SMI (I)
Employment and • IPS model to increase competitive employment rates, find jobs more quickly and keep them longer, and improve QOL (A)
education • Supported employment to improve rates of competitive employment for adults living with SMI (A)
• Occupational therapy intervention to increase probability of long-term return to work, promote long-term depression
recovery, and reduce need for other high-cost medical treatment during intervention (B)
• CR to improve attention, visual and verbal memory, and EF to enhance work skills (B)
• NET in combination with a VR program to increase hours worked and quarterly employment rates (B)
• Thinking Skills for Work program plus an enhanced supported employment program to improve cognitive function and
increase competitive employment and wages earned (B)
• Virtual reality interventions to improve cognitive measures and increase job offers (B)
• OT–PVP using skills training, combined cognitive–behavioral and skills training, and psychosocial approaches to achieve
volunteer or paid work (C)
• CAT plus TAU to improve number of hours spent in work-related activities (C)
• Psychosocial clubhouse model to increase employment duration (I)
• MIRRORS to sustain work longer and perform better in the workplace (I)
• Background classical music in the work setting to improve attention (I)
• Bridge supported education program using occupational therapy intervention to increase skill in basic academic areas and
improve professional behaviors and social skills (I)
Health and wellness • Stanford Chronic Disease Self-Management model or similar models to improve visits to primary care providers, improve
attitudes toward self-management, and increase healthy lifestyle behaviors (A)
• Yoga to reduce psychiatric symptoms such as the positive and negative symptoms of schizophrenia and anxiety (A)
• Peer coaches to help manage pain and improve use of primary care providers (B)
• Yoga to improve sleep, QOL, and postural stability (B)
• Exercise (cardiovascular, walking, recreational activities) to improve sleep for people living with depression (B)
• Exercise (cardiovascular or resistance) to improve QOL, anxiety, and depression in adults living with schizophrenia (B)
• Progressive muscle relaxation to reduce anxiety in people living with SMI (B)
• Weight loss programs (education, motivational interviewing, physical activity, ongoing support sessions, diet change) to
improve fitness levels, glucose levels, and depression (B)
• Exercise to reduce stress and anxiety in people living with SMI (C)
• Yoga to manage depression (I)
• Tai chi to manage depression (I)
(Continued)
42
C l in ic a l Re c o m m e nd at i o ns fo r I n t erven ti o n s f o r Ad u l ts Li vi n g W i th Seri o u s Men tal Illness
Table 9.1. Clinical Recommendations for Occupational Therapy Interventions for Adults Living With SMI (cont.)
Category Interventions
Early intervention • CR in early intervention for psychosis to improve cognition, self-esteem, and social and occupational performance (A)
• CBT for youth at high risk for psychosis to reduce the risk of conversion to psychosis (A)
• IPS for employment or education to improve competitive employment and education outcomes for 6 months (A)
• FPE interventions to improve social function and QOL (B)
• FPE interventions to reduce emergency room visits (B)
• CBT to reduce depressive symptoms in the short term (B)
• CBT to improve functioning (C)
• CBT to reduce depressive symptoms in the long term (C)
• IPS to improve employment rates in the long term (C)
Internalized stigma • Psychoeducation in inpatient, day treatment, and community settings for people living with SMI to reduce stigma percep-
tions and improve QOL (B)
• Group discussions to help reduce self-stigma (B)
• CBT to address perceptions of stigma (C)
• VR intervention to reduce internalized stigma and emotional discomfort (C)
• Combined SST and group support and problem solving (I)
• NET and CBT to address self-stigma (I)
• Use of PhotoVoice and group discussions to reduce self-stigma and increase sense of community activism (I)
Note. ADLs = activities of daily living; CAT = cognitive adaptation training; CBT = cognitive–behavioral therapy; CR = cognitive remediation; EF = executive function;
FPE = family psychoeducation; HOPES = Helping Older People Experience Success; IADLs = instrumental activities of daily living; IPS = individual placement and support;
MIRRORS = Mindfulness Intervention for Rehabilitation and Recovery in Schizophrenia; NET = neurocognitive enhancement therapy; OT–PVP = occupational therapy–led
prevocational program; QOL = quality of life; SCIT = Social Cognition and Interaction Training; SMI = serious mental illness; SST = social skills training; TAU = treatment
as usual; VR = vocational rehabilitation.
Criteria for level of evidence and recommendations (A, B, C, I, D) are based on standard language from the U.S. Preventive Services Task Force (2013). Suggested recom-
mendations are based on the available evidence and content experts’ clinical expertise regarding the value of using such evidence.
43
10. Case Studies
The case studies in this chapter provide examples of how to integrate and apply the findings
in clinical practice.
Box 10.1. Case Study 1. Pete—Early Intervention, Employment, and Internalized Stigma
Evaluation
Occupational Profile
Reason the client is seek- • Pete, aged 20, lives at home with his parents and 2 younger brothers. He has always been interested in
ing service and concerns video games and skateboarding. Pete has been receiving mental health services for a diagnosis of early psy-
related to engagement in chosis, and over the past 4 yr, he has experienced increasing episodes of hearing unusual noises and voices,
occupations with frequent periods of derealization. He has daily panic attacks related to the feeling that his experiences
seem unreal. He would like to develop strategies to manage his symptoms, so he can “go out and do things
and get a job like everyone else.”
Occupations in which the client
is successful • Pete completes ADLs without difficulty. He is successful when he plays familiar video games.
Barriers to occupation • Pete has withdrawn from social participation with family and peers because he has difficulty communicating
clearly. He limits his community engagement, which has resulted in reduced performance of IADLs (e.g., driv-
ing and shopping) outside the house. He no longer meets friends at the skate park.
Personal interests and values • Pete’s main interest is playing familiar video games, which he does for many hours every day. He is still inter-
ested in skateboarding but does not feel comfortable at the skate park, so he has not engaged in this activity
for almost a year. He is proud of his family’s strong work ethic, but he is concerned that his current symptoms
will prevent him from ever being able to work. Pete feels he is “different from everyone else” and is fearful of
“not fitting in.”
Occupational history • Pete “never really liked school,” and he typically got Cs. As his symptoms increased, he struggled with school
attendance and missed many days each month. With significant support from the special education staff, Pete
graduated from high school. He is very interested in having a job, but he does not have a clear sense of what
he wants to or could do in terms of a future career.
Performance patterns (routines, • Pete’s daily performance patterns include getting up around noon, dressing and grooming, taking his medica-
roles, habits, and rituals) tions, and eating whatever food his mother has prepared. He then plays video games until late at night. Pete
relies on his mother to remind him of any scheduled appointments or daily activities.
Aspects of the client’s environ- • Pete feels that his family understands him, and he is grateful that they provide a stable home and financial sup-
ments and contexts he or she port. He desires to be more independent and believes that working at a job he likes is the first necessary step.
sees as supports and barriers However, Pete is most concerned about the way his current symptoms prevent him from social participation and
to occupational engagement community engagement, and he reports being “very uncomfortable” when he leaves the house. He feels stressed
when communicating with people other than his family and is embarrassed by his reactivity to loud or unexpected
noises. Pete worries that he will be overwhelmed by the social and environmental demands of having a job.
Client’s priorities and desired • Pete identifies as priorities learning effective strategies to manage his symptoms so “I can do more things out
targeted outcomes of my house” and getting a job.
(Continued)
44
C a se Studies
Box 10.1. Case Study 1. Pete—Early Intervention, Employment, and Internalized Stigma (cont.)
Evaluation (cont.)
Analysis of Occupational Performance

COPM (Law et al., 2014) • The COPM was used to assist in completion of the occupational profile. Pete’s Performance score was 2/10,
and his Satisfaction score was 1/10 for “doing activities outside of the house.” He scored “I want a job” as
0/10 on both Performance and Satisfaction.
WCPA (Toglia, 2015) • The WCPA was used to assess Pete’s EF deficits impairing goal-directed activities. Pete demonstrated limita-
tions in planning and organization based on mental inflexibility and difficulty self-monitoring task performance.
Interview • Pete described having symptoms of anxiety with daily panic attacks “all through high school.” He acknowl-
edged having auditory hallucinations that were “distressing” and said they “got worse” when he left the
house. Pete recognized how these symptoms affected his ability to engage in the activities he wanted to do,
such as working. Pete felt he was “missing out” on becoming independent of his family and finding meaning-
ful employment.
Adolescent/Adult Sensory • To support Pete’s desire to work, the Adolescent/Adult Sensory Profile was used to determine a match for
Profile (Brown & Dunn, 2002) future work environments. Pete’s responses indicated that he had a sensory avoidance preference at the
level of “more than most people.” In discussing these results, Pete confirmed that he was most avoidant of
auditory input.
Intervention
Intervention Plan
Occupational therapy frequency and duration: 1–2 visits/wk for 12 wk in Pete’s home, the occupational therapist’s office, and the VR center
Intervention goals:
• Pete will implement 2 strategies to improve his planning, organization, and self-monitoring skills as evidenced by completion of 2 new daily
tasks each week.
• Pete will report initiating and sustaining social communication with family and peers 3×/day for periods of at least 5 min.
• Pete will implement 3 relaxation strategies to self-manage symptoms of anxiety.
• Pete will secure competitive employment through an IPS program within 3 mo.
• Pete will implement 2 strategies to reduce the impact of self-stigmatizing thinking on achieving his identified goals.
Intervention Implementation
After the initial evaluation conducted by the OT, the following interventions were provided:
• Individual sessions with Pete initially used cognitive remediation techniques to develop his awareness of his EF limitations and create effective
compensatory strategies (Holzer et al., 2014; Lee et al., 2013; Loewy et al., 2016; Mendella et al., 2015; Østergaard Christensen et al., 2014;
Puig et al., 2014).
• Using a cognitive–behavioral approach, the OTA coached Pete to identify ineffective thinking patterns and develop thinking strategies to imple-
ment in social interactions. The OTA role-modeled social communication and helped Pete initiate social communication strategies with family
members and later with others in community settings (Hutton & Taylor, 2014).
• The OTA worked with Pete on relaxation and stress management strategies for his anxiety and panic symptoms (Addington et al., 2011).
• Pete began to attend family psychoeducation group sessions with his parents (Gleeson et al., 2013). Pete was able to implement effective social
communication within these sessions. Additionally, Pete participated with his parents in education about recovery from mental illness and ways
to address self-stigma (Calvo et al., 2014). He also participated in guided discussions that involved sharing personal experiences and practicing
skills to reduce stigma and improve overall well-being (Lucksted et al., 2011).
• Pete and the OT reviewed his Sensory Profile results, which identified his preference for sensory avoidance, mainly of auditory input. They agreed
that his sensory preferences required attention in his job search. For example, they could advocate for a work environment that was quiet or,
alternatively, facilitate his adaptation to a noisy environment.
• The OT collaborated with Pete and the VR counselor to discuss Pete’s employment goals. Consistent with the IPS model for employment of
young adults at risk for psychosis, the OT and VR counselor sought Pete’s view of his job interests. Pete identified that he would need support to
identify jobs that he would be interested in and capable of doing (Baksheev et al., 2012; Killackey et al., 2008).
• The VR counselor reviewed Pete’s Social Security benefits with him to identify how many hours he could work without jeopardizing his
benefits.
• Using IPS principles, the job placement process was started immediately. To address Pete’s increased anxiety, he identified going with the OT
to visit potential work sites as a helpful job search strategy. Also, Pete was willing to share the results of his occupational therapy evaluation
with his VR counselor to help make the best possible match among his strengths, skills, and challenges and the requirements of his desired job
(Baksheev et al., 2012; Killackey et al., 2008).
(Continued)
45
Box 10.1. Case Study 1. Pete—Early Intervention, Employment, and Internalized Stigma (cont.)
Intervention (cont.)
Intervention Review
At each visit, the occupational therapy practitioner discussed with Pete his progress toward his identified goals. The OT reevaluated Pete’s status
during the last intervention visit:
• Pete and the OT reviewed his current employment process. Pete had been meeting consistently with his VR counselor, and after visiting several
potential work sites, he identified one where he “felt comfortable and liked the other workers.” He applied for and was hired into a warehouse
picker position. He had worked 4 hr the previous week for orientation with his VR counselor present. Pete reported that his anxiety symptoms
increased during the initial work hours but that he used the new strategies he had learned to manage this successfully.
• Pete reported that he was beginning to routinely use the strategies he’d learned to manage his anxiety symptoms, and this was also supporting
his social interaction skills. He described having less difficulty interacting with others, particularly in the family psychoeducation group sessions.
• Pete continued to struggle with the impact of self-stigma on his confidence regarding meeting his goals, but he was committed to continuing to
attend groups and work on this issue.
The OT–OTA team reviewed discharge recommendations and community resources with Pete. Together they researched opportunities for increasing
social interactions in his community through the local recreation and adult education centers. They encouraged ongoing attendance at the family
psychoeducation group for consistent support with problem solving and managing his symptoms to support his functional goals.
Outcomes
Overall • Pete achieved all intervention goals.

COPM • At discharge, Pete’s COPM scores improved to 5/10 for Performance and 7/10 for Satisfaction in activities outside of the house
and to 8/10 on Performance and 9/10 on Satisfaction for getting a job.
WCPA • At discharge, Pete demonstrated improvements in planning and organization, especially in managing his own daily schedule.
He continued to require assistance to self-monitor his task performance, mainly at work.
Interview • Pete acknowledged that after intervention, he felt more able to engage in daily life in spite of his symptoms. He was observed
to engage more readily in social interactions with his family and with family psychoeducation group members. Because he had
started working at a meaningful job that he liked, Pete looked forward to having a “different” life, which included the possibil-
ity of living independently.
Note. ADLs = activities of daily living; COPM = Canadian Occupational Performance Measure; EF = executive function; IADLs = instrumental activities of daily living;
IPS = individual placement and support; OT = occupational therapist; OTA = occupational therapy assistant; VR = vocational rehabilitation; WCPA = Weekly Calendar
Planning Activity.
Box 10.2. Case Study 2. Alida—ADLs, IADLs, and Leisure Management
Evaluation
Reason the client is seeking service and • Alida, aged 46, is the mother of 3 children, a daughter aged 22 and sons aged 15 and 16, and
concerns related to engagement in was divorced from her husband 6 months ago. Two weeks previously, Alida’s neighbor found her
occupations unconscious in her garage with the car running. A suicide note to her best friend and children was
found in the house. Alida was admitted to the ICU for 5 days to treat carbon monoxide poisoning;
she was then transferred to the inpatient psychiatric unit, where she was referred for occupational
therapy evaluation. Alida acknowledged that she desired to reclaim her role as mother and wanted
to have the energy to engage with her children and their activities.
Occupations in which the client is • Alida reported, “I don’t feel successful at anything.” However, she was willing to engage with the
successful OT and stated that she would try to participate in occupational therapy interventions on the unit.
Barriers to occupation • Since adolescence, Alida has experienced symptoms of major depressive disorder. Her symptoms
include periodic suicidal ideation, anhedonia, overwhelming fatigue, lack of energy and motivation
for activity, and frequent severe headaches. These symptoms have affected Alida’s engagement in
daily occupations for many years, resulting in minimal performance beyond ADLs. The limitations
from her symptoms became more intense after the divorce, which contributed to her suicide attempt.
(Continued)
46
C a se Studies
Box 10.2. Case Study 2. Alida—ADLs, IADLs, and Leisure Management (cont.)
Evaluation (cont.)
Personal interests and values • Both of Alida’s sons participate in sports. Although she feels strongly that as their mother, she
should be present at their sporting events, Alida cannot tolerate the related physical or social
demands. Alida previously enjoyed hiking and live music performances but has not participated in
either activity for several years because of lack of energy. Alida stated that she is not able to find
pleasure in anything she does.
Occupational history • Alida graduated from college with a degree in communications. Before her children were born, she
worked full time as a marketing coordinator for an insurance company for 2 1/2 years. She planned
to return to work after the children started school, but her depression symptoms interfered with her
ability to follow through on employment goals. She has now been unemployed for many years. Alida
has engaged in parenting on a full-time basis since her oldest child was born and has struggled with
this responsibility because of her depression symptoms.
Performance patterns (routines, roles, • Alida described a typical day before her admission as “crying, sleeping, and not leaving the bed all
habits, and rituals) day.” She reported showering “maybe once a week.” She stopped cooking several months ago and
reported “not eating much” because she has no appetite. On weekends, Alida forces herself to go
the grocery store and buy frozen meals that her sons can cook for the family throughout the week.
Aspects of the client’s environments • Alida reported that she feels supported by her current financial and family relationships. Alida was
and contexts he or she sees as sup- relieved to get the family home in the divorce settlement, and the alimony and child support pay-
ports and barriers to occupational ments currently support her family. Alida lives with her sons, and her daughter lives in a dorm at
engagement college. When home from school, her daughter acts as the primary caregiver in the household,
assuming responsibility for cooking, cleaning, paying bills, and organizing her brothers’ activities.
Alida’s social network includes her best friend and two other close friends, with whom she socializes
occasionally. Although Alida values her relationships with her children and friends, she is aware of
how much she has withdrawn from them over the past year. Alida stated that her friends and family
sought to help her do more outside the home, but she is fearful about her inability to socialize with
others.
Client’s priorities and desired targeted
outcomes • Alida expressed a desire to “be a mother to my children again” and “find meaning in my life.”
COPM (Law et al., 2014) • The COPM was used to assist in completion of the occupational profile. Alida’s Performance score
was 3/10, and her Satisfaction score was 2/10. Alida was very dissatisfied with her performance in
parenting, household management, and leisure and social participation.
Interview • Alida reported that she was “embarrassed” by her suicide attempt. Although she remains stressed
by her divorce and the demands of parenting her children alone, she is committed to addressing
these issues during her hospitalization and “getting my life back.”
ACLS–5 (Allen et al., 2007) and RTI–E • Alida scored 5.4 on the ACLS and on the self-reported RTI–E. These scores indicated that Alida was
(Katz, 2006) able to engage in self-directed learning and that she was a good candidate for interventions involv-
ing verbal discussion in groups.
Modified Interest Checklist (Kielhofner & • Alida identified numerous activities she previously enjoyed in which she was not currently engaging,
Neville, 1983) including cooking, jogging, kayaking, skiing, snowshoeing, hiking, and listening to live music. She
expressed a firm desire to reengage in these leisure interests.
Intervention
Intervention Plan
Occupational therapy frequency and duration: 2 occupational therapy group sessions per day for 1 hr each while hospitalized on the inpatient
psychiatric unit. Anticipated length of stay is 7 days for medication stabilization and determination of appropriate community-based intervention
programs.
Intervention goals:
1. Alida will complete self-care tasks with prompts 90% of time while hospitalized.
2. Alida will demonstrate endurance of 45 min in sustained participation in ADL and leisure tasks during hospital stay as evidenced by staying out
of bed, attending occupational therapy groups every day, and participating in informal activities.
3. Alida will create a weekly calendar with schedules for ADLs, meal preparation, and attendance at her sons’ sports activities before discharge.
4. Alida will identify a plan for realistic engagement in at least 2 leisure interests to initiate postdischarge.
5. Alida will identify at least 2 coping strategies of choice and demonstrate use of the strategies 75% of the time when she feels stressed.
(Continued)
47
Box 10.2. Case Study 2. Alida—ADLs, IADLs, and Leisure Management (cont.)
Intervention (cont.)
Alida was hospitalized for 2 wk. She did not engage in intervention groups in the first several days of her hospitalization because of severe, persis-
tent symptoms of depression resulting in difficulty getting out of bed. During this time, the OT met individually with Alida to establish therapeutic
rapport, and subsequently Alida attended at least 1, and often 2, scheduled occupational therapy sessions each day for the remainder of her
admission. After the initial evaluation and individual sessions with the OT, Alida attended both individual and psychoeducational group interven-
tion sessions designed by the OT to address her goals, as follows:
• Psychoeducational group sessions on self-management for ADLs and IADLs focused on developing new habits and routines to support Alida’s
occupational performance in her daily life (Chien et al., 2016; Helfrich & Chan, 2013; Levitt et al., 2009; Lin et al., 2013; Roldán-Merino et al.,
2013; Salyers et al., 2014). Specifically addressed were time management, including development of weekly calendars to plan for leisure partici-
pation and her sons’ sports activities; creation of menu plans for family dinners; and reestablishment of a supportive social network (Briki et al.,
2014; Bucci et al., 2013; Granholm et al., 2013; Michalak et al., 2015; Tas et al., 2012).
• Psychoeducational groups using CBT strategies addressed coping skills for relaxation and stress management (Chen et al., 2009; Vancampfort
et al., 2013; Vancampfort, De Hert, Knapen, Maurissen, et al., 2011).
• Occupation-based interventions specific to her goals. The OT worked individually with Alida to identify her family’s favorite meals and planned
intervention sessions in the unit kitchen so Alida could cook a few of these meals before discharge home. These sessions also allowed for
development of cognitive strategies for increasing and maintaining attention to tasks (Chen et al., 2015; Chien et al., 2015; Cook et al., 2009;
Fitzgerald, 2011; Katz & Keren, 2011; Kidd et al., 2014; Lindström et al., 2012; Štrkalj-Ivezić et al., 2013; Tatsumi et al., 2012; Thomas et al.,
2011; Tungpunkom et al., 2012).
• Daily yoga and walking groups on the unit to reengage in physical activity and increase her physical endurance for performing ADLs, IADLs, and
leisure activities (Cramer et al., 2013).
Intervention Review
The OT reevaluated Alida’s status during the last intervention session:
• Alida reported significant improvement in her ability to engage in desired occupations, including ADLs and IADLs. She reported feeling more
motivated and having more physical energy and a longer attention span for daily tasks. For example, Alida was “surprised” at her ability to
maintain focus on cooking tasks and yoga sessions for 1-hr periods.
• Alida described learning new stress management strategies that she would incorporate into her routine postdischarge. She consistently demonstrated and
reported positive effects from practicing progressive muscle relaxation exercises and ordered CDs that she could use at home to continue this practice.
• Alida established a new daily routine to implement at home that included engaging in physical activity, participating in leisure occupations,
cooking dinner for her family, and using time management strategies to manage her responsibilities at home.
• Alida initiated phone contact with 3 friends during her hospitalization and agreed to a visit from her best friend. They made concrete plans for
weekly contact to engage in shared leisure pursuits after discharge.
The OT reviewed discharge recommendations and community resources with Alida. They discussed the importance of avoiding isolation and main-
taining daily routines for self and family and reviewed ways to maintain reconnection with her friends and take advantage of opportunities for
increasing her social network through community-based leisure activities.
Outcomes
Overall • Alida achieved all intervention goals.

COPM • Alida’s COPM scores improved from 3/10 to 8 for Performance and from 2/10 to 8 on Satisfaction at discharge.
Interview • Alida reported feeling significantly better at discharge. She reestablished supportive relationships with her children and her
best friend and reported feeling more motivated and energetic, noting that she could “think more clearly.” She remained
concerned about a relapse of her severe depression, but she described having more skills and resources to address it than
she had prehospitalization.
Analysis of • Over the course of intervention, Alida’s attention span improved from 10-min periods to 1-hr periods of sustained focus
occupational on tasks. By discharge she independently prepared 5 familiar meals and was showering and practicing yoga daily. Alida
performance had also reconnected with her friends and made plans with them to engage in leisure activities after discharge. She dem-
onstrated consistent skill in using strategies for time management and weekly planning.
ACLS–5 and RTI–E • Occupational therapy interventions were designed on the basis of Alida’s ACLS and RTI–E scores of 5.4. She was an active
participant in verbally based psychoeducation groups and was able to follow through with recommended tasks and home-
work in a self-directed manner after group sessions.
Modified Interest • Completing the Modified Interest Checklist stimulated Alida’s desire to reengage in her leisure interests and motivated her to
Checklist improve her physical endurance to that end. She reconnected with a friend she used to jog with, and they made plans to do this
activity again after Alida’s discharge. She also discovered a new interest in yoga and planned to continue this practice at home.
Note. ACLS–5 = Allen Cognitive Level Screen, 5th ed.; ADLs = activities of daily living; CBT = cognitive–behavioral therapy; COPM = Canadian Occupational
Performance Measure; IADLs = instrumental activities of daily living; ICU = intensive care unit; OT = occupational therapist; RTI–E = Routine Task Inventory–Expanded.
48
C a se Studies
Box 10.3. Case Study 3. Ed—Social Participation and Health and Wellness
Evaluation
Reason the client is seek- • Ed, aged 56, lives alone in a small apartment in the community where he grew up. He was diagnosed with
ing service and concerns schizophrenia when he was 20 and has had many psychiatric hospital admissions. His admissions occurred
related to engagement in frequently in the early years, but he has had only two short admissions in the past 5 years. Ed’s current symp-
occupations toms include decreased concentration, difficulty initiating tasks, and overwhelming fatigue. Most of Ed’s family
members live several states away. Ed describes the staff and clients at the local community mental health cen-
ter as his only social network. He attends the day services program there 3–5 days/wk. At the center, Ed works
with his psychiatrist on medication management and participates in leisure groups. Ed identified his goals as
“losing weight and being healthy,” which he sees as the first step in moving on to other social relationships
and employment goals.
Occupations in which the cli-
ent is successful • Ed independently completes ADLs and IADLs, including household management and community mobility.
Barriers to occupation • Ed reported having gained 75 lb when he first began taking antipsychotic medications and that he has never
been able to lose weight. He fears that being overweight is a barrier to achieving his goals, which include get-
ting a job and possibly a girlfriend. Although he “knows it would help” to exercise and learn how to prepare
healthy meals for himself, Ed is particularly concerned about “getting motivated and sticking with it.”
Personal interests and values • Ed highly values his friendships and enjoys playing chess with friends at least 1×/wk. He occasionally attends
religious services at a local church and is proud of being a nonsmoker. He is a baseball fan and likes to watch
his favorite team play on TV.
Occupational history • Ed is not currently employed, and his only income is from his SSI benefits. In the past Ed used vocational reha-
bilitation services, which supported Ed to work for short periods at entry-level cleaning jobs. He reported that
he had a hard time learning and following through with assigned tasks, which caused him to lose jobs.
• In the past, Ed enjoyed being a member of a bowling league. He participated for several years during his 30’s,
but he has not had the energy for this activity since then.
• Ed takes pride in his appearance and his ability to manage his apartment, although he tires easily when com-
pleting these activities.
Performance patterns (rou- • Ed’s daily performance patterns indicate that he has difficulty with effective routines. He goes to bed in the
tines, roles, habits, and early morning hours and sleeps until noon. He completes his grooming and dressing and then walks to the
rituals) local coffee shop to eat. He attends the day services program 3–5 days/wk if he wakes up early enough. He
watches TV in the evenings. Once a month he meets with the psychiatrist at the community mental health cen-
ter for medication evaluation and management.
Aspects of the client’s envi- • Ed feels supported by his peers and the OT at day services and says said he is “at my best” when he partici-
ronments and contexts he pates there. He has a stable living situation in his current apartment. Ed is concerned that his difficulties with
or she sees as supports and concentration and organizing new tasks will keep him from getting a job. He worries about the side effects
barriers to occupational of his antipsychotic medication interfering with his goals; the medications tend to make him extremely tired,
engagement leading to oversleeping, and they also affect his sexual function. Also, Ed fears that the stigma related to hav-
ing a psychiatric diagnosis could prevent him from finding an intimate relationship.
Client’s priorities and desired • Ed wants to begin with developing an effective weight loss and exercise regimen. He feels that if he is success-
targeted outcomes ful in those areas, he will be better prepared to interact socially and consider looking for work again.
COPM (Law et al., 2014) • The COPM was used to assist in completion of the occupational profile. Ed’s self-reported Performance score
was 2/10, and his Satisfaction score was 2/10. Ed was very dissatisfied with his performance in self-care activi-
ties involving healthy eating and exercising and with his social participation.
Interview • Ed expressed concern about his ability to follow through with attending the Day Services Program, even
though he felt confident the program would assist him in meeting his goals. He stated that he wished he
“could do better with a healthy lifestyle” and that this would be the foundation for achieving his work and
relationship goals.
ACLS–5 (Allen et al., 2007) • Ed’s scores on the ACLS–5 and RTI–E were 5.0, indicating that he could benefit from assistance to establish a
and RTI–E (Katz, 2006) balance of work, rest, leisure, and exercise opportunities in a daily and weekly routine and to develop strate-
gies for follow-through. These scores also indicated that environmental cues could promote Ed’s success with
ADLs, IADLs, and time management and that a structured daily and weekly routine could support and main-
tain his recovery.
(Continued)
49
Box 10.3. Case Study 3. Ed—Social Participation and Health and Wellness (cont.)
Intervention
Intervention Plan
Occupational therapy frequency and duration: Ed will attend the day services program at the community mental health center 3 days/wk for 8 wk.
He will participate in individual and group occupational therapy sessions 2×/day.
Intervention goals:
1. Ed will improve his ability to manage his health and participate in ADLs and IADLs by developing and following an established 30-min strength
and walking exercise program 3×/wk.
2. Ed will identify healthful, low-cost meal options and produce monthly meal plans to follow at home to support effective weight management.
3. Ed will budget for food within his monthly income to support effective weight management.
4. Ed will grocery shop weekly with the support of an OTA to compare prices and make food purchases within his weekly food budget.
5. Ed will prepare meals daily, following the meal plans 50% of the time by the end of 8 wk.
6. Ed will identify 1–3 recreational activities through which he will meet others not connected to the day services program and attend 3–5 events
by the end of 8 wk.
Ed attended one or two occupational therapy sessions on each day he went to day services. His overall attendance averaged 1–2 days/wk because
he frequently missed days because of oversleeping. After the initial evaluation, the occupational therapy practitioner implemented the following
interventions:
• Ed participated in individual sessions with the OTA focused on skill development for meal planning, budgeting for groceries, and grocery shop-
ping (Clark et al., 2015; Lindström et al., 2012).
• The occupational therapy practitioner used a manualized psychoeducation approach to facilitate healthy lifestyle group sessions in which mem-
bers learned strategies to address their weight loss goals (Brown et al., 2014).
• Another group intervention was a community-based gym group held at a local gym. The occupational therapy practitioner helped members
establish a personalized exercise regimen with the personal trainer and then worked with members on developing a schedule for consistent
gym attendance (Marzolini et al., 2009; Scheewe et al., 2013).
• The OT facilitated Ed’s engagement in group interventions to increase his social participation (Cook et al., 2009; Štrkalj-Ivezić et al., 2013;
Tatsumi et al., 2012). The OTA then helped Ed explore leisure options to support him in developing new social networks outside the day ser-
vices program.
Intervention Review
Each week, the occupational therapy practitioner reviewed with Ed his progress toward his identified goals. By discharge, Ed had made good
progress on each of his goals.
• The occupational therapy practitioner reevaluated Ed’s status during the last intervention visit:
○ Ed reported significant improvement in his ability to plan and make healthful meals for himself and was pleased to have a monthly menu to
follow. Ed stated that he prepared planned meals at least 3 days/wk, which was close to the goal of meal preparation 50% of the time.
○ Ed and two other clients at the day services program arranged for transportation so they could continue to exercise at the gym 3×/wk after
discharge.
○ Ed and two peers attended three free community concerts during 8 wk.
• The occupational therapy practitioner reviewed discharge recommendations and community resources with Ed. They discussed opportunities for
increasing social interactions in his local community through the peer center and his religious institution. They also discussed a plan for Ed to
follow when he decided to pursue employment.
Outcomes
COPM • Ed’s COPM scores improved from 2/10 to 5/10 for Performance and from 2/10 to 7/10 on Satisfaction at discharge.
Interview • Ed said he was “grateful” for the time he spent in Day Services. He stated that although he knew what he wanted to
accomplish, he wasn’t able to get started on his goals without the support from Day Services. He reported feeling hopeful
about maintaining a healthy lifestyle and eventually achieving his employment and relationship goals.
ACLS–5 and • Occupational therapy interventions were designed for Ed on the basis of his ACLS–5 and RTI–E scores of 5.0. He collabo-
RTI–E rated with the occupational therapy practitioner to develop new routines for grocery shopping, meal preparation, and exer-
cise and began using visual reminders (i.e., a whiteboard in his kitchen, sticky notes on his bathroom mirror), checklists, and
a weekly planner to support and maintain this effective structure.
Note. ACLS–5 = Allen Cognitive Level Screen, 5th ed.; ADLs = activities of daily living; COPM = Canadian Occupational Performance Measure; IADLs = instrumental
activities of daily living; OT = occupational therapist; OTA = occupational therapy assistant; RTI–E = Routine Task Inventory–Expanded; SSI = Supplemental Security
Income.
50
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Appendix A.
Evidence and Risk-of-Bias Tables
• Table A.1. Evidence Table for the Systematic Review of Interventions to Promote ADLs
and IADLs, Rest and Sleep, Leisure, and Social Participation for Adults Living With
SMI��A2
• Table A.2. Risk-of-Bias Analysis for Intervention Studies Included in the Systematic
• Table A.3. Risk-of-Bias Analysis for Systematic Reviews Included in the Systematic
• Table A.4. Evidence Table for the Systematic Review of Interventions to Support
Employment and Education for Adults Living With SMI��A31
With SMI��A67
With SMI��A70
• Table A.7. Evidence Table for the Systematic Review of Interventions to Promote
Health and Wellness for Adults Living With SMI��A71
Review of Interventions to Promote Health and Wellness for Adults Living With
SMI��A104
Review of Interventions to Promote Health and Wellness for Adults Living With
SMI��A108
• Table A.10. Evidence Table for the Systematic Review of Early Intervention for
Adolescents and Young Adults Living With SMI��A110
Review of Early Intervention for Adolescents and Young Adults Living With SMI��A122
Review of Early Intervention for Adolescents and Young Adults Living With SMI��A124
• Table A.13. Evidence Table for the Systematic Review of Interventions to Reduce
Internalized Stigma for Adults Living With SMI��A125
Review of Interventions to Reduce Internalized Stigma for Adults Living With SMI��A136
Review of Interventions to Reduce Internalized Stigma for Adults Living With SMI��A138
A1
Table A.1. Evidence Table for the Systematic Review of Interventions to Promote ADLs and IADLs, Rest and Sleep, Leisure, and Social Participation for Adults
Living With SMI
Level of Evidence/Study Design/

Author/Year Participants/Inclusion Criteria Intervention and Control Outcome Measures Results
Occupation-Based Interventions
Berget et al. (2008) Level I Intervention • Generalized Self-Efficacy Scale A significant increase in self-efficacy was
Animal-assisted therapy, 3-hr visits to • Coping Strategies Scale found in the intervention group but not
RCT farm 2×/wk • Norwegian QLS in the control group from before interven-
N = 90 (34.4% men; M age = 34.7 yr). tion to 6-mo follow-up, F(1, 55) = 4.20,
Control p = .05, and from end of intervention to
Intervention group, n = 60. Standard therapy (individual, group, or follow-up, F(1, 55) = 5.6, p = .02. The
other) intervention group showed a significant
Control group, n = 30.
increase in coping ability at follow-up,
Inclusion criteria: Schizophrenia or schizo- t = 2.31, p = .03. No change was found
typal disorder, affective disorder, anxiety in QOL.
and stress-related disorder, or disorder of
adult personality and behavior; half had
been ill for >5 yr; 2/3 treated in psychiatric
institutions; most on medications (Norway)
Carta et al. (2014) Level I Intervention • WHOQOL Sailing training and participation
Sailing monthly and weekly, weekly • BPRS improved QOL in the short term, but
RCT crossover with blinding social skills training and leisure sessions • HoNOS after 12 mo measures returned to
N = 40 (95% men; M age = 39 yr). on sailing, bimonthly expeditions to • GAF baseline. No change was found in social
open sea on a sailing boat relationships.
Intervention group, n = 20.
Control This pleasurable activity interrupted
Control group, n = 20. Wait list, traditional rehabilitation chronicity, but with loss of activity, par-
activities ticipants returned to baseline.
Inclusion criteria: Outpatients with a
severe psychopathological condition, in
treatment, ≥2 yr in clinical remission
Chen et al. (2015) Level I Intervention • Function and QOL: WHOQOL– The intervention group showed
Life Adaptation Skills Training, an BREF Taiwan version, OSA, decreased anxiety and suicidal ide-
RCT OT-delivered program focused on life- OSA–Environment ation for up to 3 mo postintervention
N = 68 (18 men, 50 women; M age = style rearrangement and coping skills • Mastery: Social Support (p ≤ .05). Both groups demonstrated
48.85 yr). enhancement, plus phone contact Questionnaire improvement in QOL, with the interven-
support, 24 10-min sessions 2×/wk for • Symptoms: BAI, BDI–II, Beck Scale for tion group having greater improvement.
Intervention group, n = 33. 12 wk Suicidal Ideation
Interpretation of findings is limited by
Control group, n = 35. Control the small sample size.
Oc c u p atio n a l T herap y Pra ct i c e G ui de l i n es f or A d u l ts Li vi n g W i th Ser i ou s M en tal Il l ness
Phone contact support only, 24 sessions

Inclusion criteria: MDD or dysthymia, age
2×wk for 12 wk
≥18 yr, Mini-Mental State Exam score
A2
≥24, in maintenance phase of disorder,
receiving outpatient services, literate
(Continued)
Living With SMI (cont.)

Chu et al. (2009) Level I Intervention Self-report questionnaires assessing self- Intervention participants improved in
Animal-assisted therapy, 50 min 1×/wk esteem, self-determination, extent of self-perception, well-being, positive
RCT for 8 wk social support, increases and decreases symptoms, and emotional symptoms
N = 30. in psychiatric symptoms, self-repulsion, (p ≤ .05). No significant improvements
Control and nurse-reported daily activities of were found in social support and nega-
Intervention group, n = 15. TAU patients tive symptoms.
Inclusion criteria: Inpatient adults ages

<60 yr with diagnosis of schizophrenia
for >10 yr, no cognitive impairment, no
other experimental treatment (Taiwan)
Clark et al. (2015) Level III Intervention • 24-hr recall of participation in The intervention group improved in use
Cooking Matters for Adults, a 6-wk program of nutritious food and grocery shopping
Pre–post single cohort nutrition and education cooking class • Cooking Matters survey and self-perception of improved cooking
N = 18 (72% women; M age = 39). using social learning theory that skills.
includes cooking on a budget, grocery
Inclusion criteria: Convenience sample shopping skills, food safety, and ways This study provides low-level evidence
of adults with SMI, desire to manage to increase intake of fruit, vegetables, but is occupation based.
weight or improve eating habits and calcium while decreasing salt and
fat in diet
Cook et al. (2009) Level I Intervention • SFS Both groups improved in social function
OT with an individualized and client- • SANS and SANS scores; the intervention group
RCT pilot centered approach comprising 82 com- • Employment showed clinically significant improve-
N = 44 (64% women; M age = 46.6 yr). ponents in 11 stages of the OT process, ment in social functioning subscales,
12 mo whereas the control group did not. No
Intervention group, n = 30. differences between groups reached
Control statistical significance.
Control group, n = 14. TAU (no OT)
Inclusion criteria: Adults with diagnosis
of psychosis for any duration, eligibility
for an enhanced care program, age ≥21
yr, score of ≥2 on ≥1 of the HoNOS
scales for problems with ADLs, disabil-
ity, or occupation and activities
(Continued)
A3
A ppen d i x A . Evi d en c e an d Ri sk-o f -Bi as Tab les

Cramer et al. (2013) Level I Intervention • Symptoms: BPRS, PANSS Moderate evidence was found for short-
Yoga consisting of physical activity, • QOL: WHOQOL–BREF term effects of yoga on QOL. No recom-
Systematic review and meta-analysis breath control, meditation, and lifestyle • Cognitive function: CGI, mendation can be made for yoga as a
N = 5 studies. advice based on yoga tradition (e.g., MATRICS–NIMH routine intervention for patients with
Yogasana, Hatha yoga) in sessions last- • Social function: SOFS schizophrenia.
N = 337 participants (31%–60% ing 30–60 min, 2–5×/wk for 8 wk to • Hospitalization
women, Mdn = 33.3%; M age = 28.2– 4 mo • Safety
48.1 yr, Mdn = 32.5).
Control
Inclusion criteria: RCTs and random- TAU, exercise, or other nonpharmaco-
ized crossover studies published as full logical intervention for 8 wk to 4 mo
papers; yoga interventions; adult partici-
pants diagnosed with schizophrenia or
being treated for schizophrenia
Fitzgerald (2011) Level II Intervention MOHOST The intervention group demonstrated

TAU + Social Inclusion Program consist- significant improvement in motivation
2-group nonrandomized controlled ing of a coherent set of interventions for occupation and patterns of occu-
N = 43 (83.7% men; M age = 36.5 yr). guided toward participant goals and pation, demonstrating that OT using
graded outcomes, provided and regu- social inclusion interventions improves
Intervention group, n = 24. larly reviewed by an OT team occupational performance for forensic
service uses.
Control group, n = 19. Control
TAU
Inclusion criteria: Age 21–59 yr, diagno-
sis of schizophrenia (37), schizoaffective
disorder (4), or bipolar disorder (2),
residing in a forensic unit, self-selected
to participate in intervention
Helfrich & Chan (2013) Level III Intervention • OSA Top priorities and competencies
OT-led group consisting of life skills psy- • Self-reported priorities, competencies, remained high across time. Multiple per-
1 group repeated measures, partly choeducational materials and applied and values ceptions of competencies increased over
feasibility activities addressing room and self- time. Values remained high across time.
N = 73 (56% men; M age = 46.3 yr). care management, food management,
money management, and safe commu- Differences were noted between partici-
Inclusion criteria: Convenience sample; nity participation, weekly 60-min group pants with affective disorders and those
ability to give informed consent, iden- and individual sessions with thought disorders and in different
tify a life skill need, and engage in types of residence.
intervention Control
No control
A4
(Continued)

Katz & Keren (2011) Level II Intervention • WCST Intervention 1 was effective in improv-
Group 1: Occupational goal intervention • WAIS–III Digit Span ing both EF and daily activity and
3 groups, quasi-experimental, random emphasizing the use of functional activi- • Behavioral Assessment of participation. Intervention 2 showed
assignment ties in 3 main domains: (1) food prepa- Dysexecutive Syndrome effectiveness on formal EF measures.
N = 18 (66.7% men; M age = 30 yr, ration; (2) money management; and (3) • Executive Functions Performance Test Both intervention groups showed
range = 22–38 yr). reading, writing, and using computers • Routine Task Inventory–Expanded greater benefits than the control group.
for information seeking • Activity Card Sort
Intervention Group 1, n = 6. • Reintegration to Normal Living Index
Group 2: Frontal executive program of
Intervention Group 2, n = 6. neurocognitive rehabilitation
Activity training approach, 18 sessions
Inclusion criteria: Schizophrenia, deficits
over 6–8 wk
in EF, age 20–55 yr
Lindström et al. (2012) Level III Intervention: • GAS The intervention was effective as indi-
OT everyday-life rehabilitation program • Assessment of Motor and Process cated by improvements in measures
Prospective pretest, posttest, and characterized by close collaboration, a Skills of goal attainment, occupation, and
follow-up test design recovery focus, client centeredness, goal • Assessment of Social Interaction health-related factors.
N = 17 (58.8% men; M age = 48 yr). setting based on user choices, occupa- • Satisfaction With Daily Occupations
tion-based training in real-life settings, • ADL taxonomy with an effort scale
Inclusion criteria: Residents of sheltered individually set time frames, and support • Symptom Check List–90
or supported housing, severe conse- during a maintenance phase after goal
quences in everyday life resulting from attainment; varied from 2 to 17 mo
schizophrenia or other psychotic disorder, based on client
high level of assistance by community
care workers within the housing, moti- Control
vation to participate in rehabilitation No control
focused on daily occupations (Sweden)
Rethorst et al. (2013) Level I Intervention Inventory of Depressive Symptoms, Both groups showed significant
SSRI + public health dose of exercise in with 4 sleep-related items: sleep onset decreases in total insomnia (p < .0001),
RCT supervised sessions at clinic with addi- insomnia, midnocturnal insomnia, early sleep onset, and midnocturnal and
N = 122 (82% women; M age = 47 yr). tional home-based sessions over 12 wk morning insomnia, and hypersomnia early morning insomnia (p < .002).
Hypersomnia did not change signifi-
Intervention group, n = 61. Control cantly (p = .38). No significant differ-
SSRI + low dose of aerobic exercise in ences were found between groups.
Control group, n = 61. supervised sessions at clinic with addi-
tional home-based sessions over 12 wk
Inclusion criteria: Outpatients age 18–70
yr, diagnosis of nonremitted MDD
A5
(Continued)

Roldán-Merino et al. (2013) Level I Intervention • Katz Index of ADLs The intervention group showed signifi-
Nursing home visits and practice in daily • Lawton and Brody Index for IADLs cantly increased independence in IADLs
RCT life skills in home environment including • F amily Problems Questionnaire (p = .02).
N = 94 (69.1% men; M age = 45.9 yr). (but not limited to) shopping, house-
work, physical health, and medication The intervention improved levels of
Intervention group, n = 47. management family burden as shown by the Help
Received (p = .001) and Positive Activity
Control group, n = 47. Control subscales (p = .02) of the Family
Mental health center visits, control of Problems Questionnaire.
Inclusion criteria: Diagnosis of schizo-
symptoms, support of ADL management
phrenia, age 18–64 yr, active history
in health center with evolution of ≥2 yr
since diagnosis
Štrkalj-Ivezic’ et al. (2013) Level I Intervention • OSA The intervention group showed bet-
Rehabilitation day center providing • Manchester Assessment of Quality of ter results (p < .001) than the control
RCT interventions such as social and life Life Scale group in social functioning, QOL, and
N = 98 (52% men; M age = 42 yr). skills, relapse prevention strategies, and • RSES self-esteem.
OT, with monthly visits to psychiatrist
Intervention group, n = 50. and medication over 6 mo
Wait list, monthly visits to psychiatrist
and medication
phrenia for ≥5 yr
Tatsumi et al. (2012) Level I Intervention • Interpersonal relationships via mea- The intervention group showed signifi-
TAU plus cooking and teatime facili- surement of angle and distance from cant improvement in SANS total and
RCT tated by OTs, 15 weekly 1-hr sessions interviewer during interview Avolition–Apathy and Anhedonia–
N = 38 (89% men; M age = ∼57 yr). • SANS Asociality subscale scores and in POMS
Control • BPRS total and Anger–Hostility subscale
Intervention group, n = 19. TAU plus teatime only facilitated by OTs, • Rehabilitation Evaluation scores. The control group did not show
15 weekly 1-hr sessions • Hall and Baker Scale any significant improvement.
• POMS
Interpersonal relationships improved sig-
Inclusion criteria: Inpatients with diagnosis
nificantly for the intervention group as
of schizophrenia, disease duration of ≥10
reflected in decreases in angle of seat-
yr, no work experience after onset because
ing and distance after cooking activities.
of disease condition, rejection or negative
involvement in treatments including pro-
Oc c u p at io n a l T h era p y Pra c t i c e G u i d e l i n e s f or A d u l ts Li vi n g W i t h Ser io u s M e nta l I l l n ess
grams in an OT room, psychological evalu-

ation and social skills training, approval to
A6
participate by attending physician
(Continued)

Thomas et al. (2011) Level I Intervention • GAS The intervention resulted in improved
OT including life skills, empowerment, • Practical Skills Test skills, but results varied over time and
Systematic review ADLs, IADLs, safe community participa- • OSA across skill areas.
N = 7 studies (3 Level III, 4 Level IV). tion, and employment • GAF
• Life Skills Assessment Identified occupational needs included
N = 257 participants (2 studies exclu- Control • Kohlman Evaluation of Living Skills money management, coping skills,
sively women; 5 studies primarily men; No control conditions employment and education, and leisure
M ages not reported). activities.
Inclusion criteria: Research studies A need for high-level research was seen.
with clearly recognizable research Of 7 studies reviewed, 3 reported effec-
methodology that supported results tiveness of interventions with homeless
and conclusions of study; included par- participants; limited evidence was pro-
ticipants who were either currently or vided of the value of traditional OT with
recently homeless; articles evaluating homeless people. The lack of evidence
OT programs, occupations, or identi- of effectiveness of OT may be attribut-
fied occupational needs of homeless able to the contexts of homelessness.
people
Psychoeducation
Batista et al. (2011) Level I Intervention • Clinical course: time to recurrence Psychosocial education improved social
Psychoeducation provided primarily in or relapse, symptom severity, days functioning and medication and treat-
Systematic review groups; 2 studies provided it individually hospitalized ment adherence, increased knowledge
N = 13 RCTs. and 2 groups included family or others; • Treatment adherence about illness in patients and family par-
program length varied from 5 to 21 • Psychosocial functioning ticipants, and decreased time in hospital
Inclusion criteria: RCTs that used only sessions, and follow-up varied from 6 and to relapse.
psychoeducation plus medication mo to 5 yr
Control
Not reported (TAU implied)
Bond & Anderson (2015) Level I Intervention • Relapse Moderate evidence indicates that
Psychoeducation in groups, individually, • Sensitivity analyses psychoeducation improved medication
Systematic review or including family or caregivers, includ- • Severity of mood adherence, that group delivery and
N = 16 RCTs. ing information about the disorder, • QOL longer delivery models were more ben-
interventions including medications, • Functioning eficial than individual psychoeducation
based on models by Colom and Vieta
(Continued)
A7

Inclusion criteria: RCTs comparing psy- relapse patterns and prevention, cop- (2006) and Bauer and McBride (2003),
choeducation to TAU related to bipolar ing strategies, lifestyle changes, and and that creating individualized action
disorder, published before September personal action plans; sessions varied plans may prevent manic relapse.
2013 from 2 to 21, follow-up ranged from 42
to 104 wk No consistent effects on functioning or
QOL were found.
Control
TAU, placebo
Chien et al. (2015) Level I Intervention • Sleep quality: PSQI Intervention participants experienced
TAU (including nursing and OT inter- • BPRS significantly improved sleep quality and
RCT repeated measures ventions) plus a cognitive–behavioral • H eart rate analyzer improved heart rate variability compared
N = 89 (52% men; M age = 28.5 yr). intervention combined with breathing with control participants.
relaxation exercises including muscle relax-
Intervention group, n = 43. ation, deep breathing, and sleep hygiene
TAU
Inclusion criteria: Diagnosis of MDD,
PSQI score >5, ability to answer
questions
Chien et al. (2016) Level I Intervention • Adherence Rating Scale The intervention group showed
Adherence therapy, a motivational • PANSS improved insight on illness and treat-
RCT interview–based program consisting of • Specific Levels of Functioning Scale ment, improved levels of functioning,
N = 134 (53% men; M age = 29 yr). medication adherence training; home • Insight and Treatment Attitudes and decreased symptom severity and
visits including culturally relevant, cogni- Questionnaire duration of hospitalization.
Intervention group, n = 67. tive, motivational, insight-inducing, and • Rehospitalization
behavioral training; problem-solving, • DAI
symptom-management, and coping
Inclusion criteria: Outpatients with skills; behavioral rehearsals of adher-
schizophrenia spectrum disorder from 2 ence; illness education; social network
community psychiatric nursing services, and relationships; function related to
willing to participate, age 18–64 yr, ADL, social, and community-living skills;
≤3 yr from illness onset, proficient in implemented by psychiatric nurses, but
Mandarin or Cantonese, poor adherence other health professionals can provide
or nonadherence to medication (Hong program with training; 2-hr sessions over
Kong) 12 wk
Control
TAU
A8
(Continued)

Levitt et al. (2009) Level I Intervention • Illness management and pursuit of The intervention group showed sig-
Psychoeducation sessions on topics recovery goals nificantly greater improvements than the
RCT including (but not limited to) recovery • QOL control group in ratings of illness manage-
N = 104 (63.5% men; M age = 54 yr). strategies, social support, medications, • Psychiatric symptoms ment, psychiatric symptoms, and QOL.
drug and alcohol use, relapses, coping, • Suicidality
Intervention group, n = 54. and navigating the mental health sys- • Substance use Intervention participants demonstrated
tem, 2×/wk for ∼20 wk, plus TAU (i.e., • Psychiatric hospitalizations significantly greater improvement in ill-
Control group, n = 50. ness self-management and psychosocial
supportive housing, case management, • Employment status
psychiatric treatment and primary medi- • Interest in employment functioning and greater reduction in
Inclusion criteria: Serious and persistent
cal care, referral to and coordination with BPRS total and Depression–Anxiety sub-
mental illness, current residence in 1 of
community-based services, recreational scale scores.
3 supportive housing sites, proficiency
in English, willing to provide informed and therapeutic facilities and activities) No effects were found for secondary
consent outcomes such as suicidal behavior and
Control
Wait list, TAU substance abuse.
Lin et al. (2013) Level I Intervention • Illness self-management knowledge The intervention group showed sig-
Adapted Illness Management and and attitudes toward medication: nificant improvement in illness self-
RCT Recovery program consisting of talk Knowledge of Illness Scale management, including knowledge,
N = 97 (64% men; M age = 35 yr). therapy with role-playing and CBT, • DAI–30 attitudes toward medication, and insight
90-min sessions 2×/wk for 3 wk then • Insight and symptoms: semistructured into the illness; the control group did
Intervention group, n = 48. 1-mo follow-up interviews not.
• Schedule for Assessing Insight–E
Control group, n = 49. Control • BPRS
TAU
phrenia or schizoaffective disorder, hos-
pitalized for ≥2 wk, clinically stabilized
and hospital discharge expected in 2–4
wk (Taiwan)
Pandor et al. (2015) Level I Intervention • Behavioral outcomes: no. of sexual Results were mostly mixed and inconclu-
Sexual health risk reduction interven- partners; unprotected anal, vaginal, sive because of heterogeneity of studies
Systematic review tions including social skills, role-playing, and oral intercourse; knowledge; and small sample sizes.
N = 13 studies. problem solving, CBT, education, small attitudes; beliefs; intentions; skills
groups, assertiveness and negotiation
(Continued)
A9

N = ∼1,936 participants (3 studies skills training, communication skills, plus • Biological outcomes: decreased HIV, Some support was found for small-
consisted of all women; 4 studies, TAU; interventions provided by trained substance abuse risk reduction group interventions, skills training, CBT,
all men; 1 study had a ratio of 2:1 facilitators, licensed mental health role-playing, and education to promote
men to women; 5 studies averaged counselors, mental health professionals, increases in condom use, protected
about 47% men; M age range = or psychologists; varied length of time intercourse, and knowledge of HIV.
36–42 yr). (4–15 sessions), frequency, and delivery
methods; follow-up ranging from 2 wk
Intervention groups, n ∼ 1,246. to 18 mo
Control groups, n ∼ 690. Control
Inclusion criteria: Controlled trials TAU, usually including education ses-
examining sexual health interventions; sions on HIV, money management, or
participants age ≥18 yr with SMI living HIV and substance misuse; wait list or
in the community, >50% with psychotic no treatment; or health promotion cov-
diagnosis ering a variety of topics
Salyers et al. (2014) Level I Intervention • PANSS Participants in both groups improved
OT-related training on Illness • QLS significantly in domains related to illness
RCT Management and Recovery including • Illness Management and Recovery management, including symptoms, psy-
N = 118 (including 56 veterans; 80% psychoeducation, cognitive–behavioral Scale chosocial functioning, self-rated illness
men; M age = 48 yr). approaches to medication adherence, • Patient Activation Measure management, and emergency depart-
relapse prevention, social skills training, • Morisky Scale ment use.
Intervention group, n = 60. and coping skills training in 10 topic • Recovery Assessment Scale
modules taught individually or in groups • State Hope Scale No significant differences were found
Control group, n = 58. between groups, possibly as an effect of
over 9 mo
mutual support and low participation in
Inclusion criteria: Currently receiving or
Control both groups.
newly admitted to mental health ser-
Problem solving over 9 mo
vices at the Veterans Affairs or commu-
nity mental health center, age ≥18 yr,
diagnosis of schizophrenia or schizoaf-
fective disorder, willing and able to give
informed consent
Swildens et al. (2011) Level I Intervention Primary The intervention group showed higher
Boston Psychiatric Rehabilitation Goal attainment in 3 categories: voca- rates of goal attainment than the con-
RCT approach, which includes setting a goal, tional or educational, social contacts, trol group. Goal attainment was more
N = 156 (50% women; Mdn age = planning interventions, and carrying living situation successful for goals that that involved
31–50 yr). them out, in individualized sessions at social participation and social contacts
least every 3 wk than for goals involving living situation.
A10
(Continued)

Intervention group, n = 80. Control Secondary QOL increased over time to an equal
TAU, individualized sessions at least • SFS degree for both groups. No changes
Control group, n = 76. every 3 wk • Change in work situation and inde- were found in social functioning or inde-
Inclusion criteria: Desire for positive pendent living pendent living.
change in 1 of the rehabilitation areas • Personal Empowerment Scale
and willingness to participate in a reha- • Camberwell Assessment of Need
bilitation process • Short Appraisal Schedule
• WHOQOL
vanderVoort et al. (2015) Level I Intervention • Functioning Assessment Short Test Intervention participants demonstrated
Collaborative Care, a manualized pro- • WHOQOL–BREF overall improved functioning; however,
RCT controlled cluster gram that includes the health care team, no group differences were found in
N = 138 (64% women; M age = 45.5 patient, and family or caregiver in estab- work function, financial issues, social
yr). lishing goals and a treatment plan as a life, or overall QOL.
contract, as well as needs assessment,
Intervention group, n = 56. mood charting, psychoeducation, and
problem solving, directed primarily by a
nurse or provided by nurses trained in
Inclusion criteria: Outpatients with bipo- the manualized program, plus TAU
lar disorder, age 18–65 yr
Control
TAU
Walsh et al. (2014) Level I Intervention Various outcome measures including Evidence was mixed, with limited long-
Behavioral (nonpharmacological) inter- self-report, vaginal episode equivalent term changes found. However, emerg-
Systematic review ventions aimed at promoting sexual index, incidents of unprotected sexual ing evidence suggests that behavioral
N = 11 studies. safety-taking behaviors delivered in activity, condom use intervention has the potential to reduce
any psychiatric setting, including psy- sexual risks in people with SMI in the
N = 1,463 participants (some studies chosocial treatment, skills training in short term.
predominantly men, others predomi- communication and assertiveness, CBT,
nantly women; average ∼50%; M ages education, social skills training, role-
not reported). playing, videos, mostly group-based
psychosocial interventions, and motiva-
Inclusion criteria: RCTs; adult participants
tional enhancement or interviewing
of any age diagnosed with SMI (schizo-
phrenia, schizoaffective disorder, bipolar Control
disorder, MDD), no nonpsychotic illnesses, TAU or comparison intervention
receiving secondary mental health care
(Continued)
A11

Xia et al. (2013) Level I Intervention • Diagnostic criteria Compared with psychoeducation, stan-
Psychoeducation in addition to standard • Assessments of knowledge, behavior, dard care produced more improvement
Systematic review care social functioning, global state, men- in illness knowledge.
N = 44 studies. tal state, expressed emotion, QOL,
Control satisfaction with care Included studies provided poor-quality
N = 5,142 participants. Standard care alone evidence, but psychoeducation seems to
have benefits in medication adherence
Inclusion criteria: RCTs using psychoedu- and decreased relapse rates, hospital
cation for individuals or groups of adults readmissions, lengths of stay, and costs.
with schizophrenia or schizophreniform,
schizoaffective, or schizotypal disorders Psychoeducation resulted in improved
social function and satisfaction with
mental health services and QOL.
This review provides some support

for psychoeducation for people with
schizophrenia.
Skills Training
Almerie et al. (2015) Level I Intervention • Social functioning: WHO–DAS, Social Social skills programs resulted in
Social skills programs including role- Avoidance and Disability Scale, SDSS, improved social functioning and QOL
Systematic review playing and modeling, with follow-up SSPI, Social Situations Questionnaire, and decreased hospitalization and
N = 13 studies. ranging from 8 to 52 wk SBS, SFS, Conversations With a relapse compared with standard care.
Stranger Task No significant differences in outcomes
N = 975 participants (M age = 33–48 Control • Relapse were found between social skills pro-
yr; average percentages appear higher Standard care or discussion group • Rehospitalization grams and discussion groups.
for men). • Mental state: symptoms, BPRS,
SANS, Scale for the Assessment of Strength of evidence varied among
Inclusion criteria: RCTs with double studies included. Further investigation is
Positive Symptoms
blinding, participants with schizophrenia warranted.
• Global state: CGI, GAS
• General functioning: Morningside
Rehabilitation Status Scale
• QOL: General Well-Being Scale, QLS,
RSES
(Continued)
A12

Bartels, Pratt, Mueser, Level I Intervention • Independent living: ILSS, The intervention group showed
Forester, et al. (2014) HOPES, a 12-mo psychosocial skills MCAS, UPSA, SBS, Self-Efficacy Scale improved community living skills and
RCT training and preventive health care • Symptoms: BPRS, SANS, Center for functioning, greater self-efficacy, lower
N = 183 (58% women; M age = 60.2 intervention consisting of weekly train- Epidemiologic Studies Depression symptoms, and greater use of preventive
yr). ing, twice-monthly community practice Scale, SF–36, Charlson Comorbidity health care compared with the control
trips, and monthly nurse preventive Index, self-report, medical record group at 3-yr follow-up.
Intervention group, n = 90. health care visits followed by a 1-yr review
maintenance phase of monthly sessions
Control
Inclusion criteria: Age ≥50 yr;
TAU
recruited from 2 community mental
health agencies; able and willing
to provide informed consent; Axis I
disorder of schizophrenia, schizoaf-
fective disorder, bipolar disorder,
or major depression with persistent
impairment in multiple areas of
functioning
Gibson et al. (2011) Level I Interventions • Social participation (e.g., social skills Moderate to strong evidence was found
Social participation (including social training) for the efficacy of social skills training.
Systematic review skills training), IADLs (including life • IADLs (e.g., life skills training, physi- Moderate evidence was found for the
N = 52 articles. skills training and physical activity), cal activity) efficacy of life skills and IADL training,
neurocognitive training, client-centered • Neurocognitive training as well as of neurocognitive training
Inclusion criteria: Articles published inintervention • Intensity and duration of intervention paired with life skills.
English in a peer-reviewed journal; stud- • Client-centered intervention
ies used interventions within scope of Control • Context and environment of The evidence supporting client-
OT practice; participants with diagnosis TAU intervention centered treatment and intensity and
of SMI, age 18–65 yr duration of treatment was limited but
positive; the evidence regarding con-
text and environment of intervention
was inconclusive.
Mueser et al. (2010) Level I Intervention • UPSA Significant differences favoring the
TAU + HOPES weekly skills classes on • MCAS intervention were found in scores on the
RCT communicating effectively, making and • SBS UPSA, MCAS, ILSS Leisure and
(Continued)
A13

N = 183 (57.9% women; M age = 60 keeping friends, making the most of • ILSS Recreation subscales, RSES, and SANS.
yr). leisure time, healthy living, using medi- • RSES Findings confirm that HOPES program-
cations effectively, and making the most • SANS ming can provide benefits for older
Intervention group, n = 90. of a health care visit, plus community • Delis–Kaplan Executive Functioning adults with SMI. Men benefited more
Control group, n = 93. practice trips and 1:1 meetings with a System than women.
nurse
Inclusion criteria: Adults with diagnosis Intervention participants improved more
of major depression, bipolar disorder, Control in social skills, community functioning,
schizoaffective disorder, or schizophre- TAU including pharmacotherapy, case negative symptoms, self-efficacy, and
nia; age ≥50 yr; able and willing to management or outreach by non-nurses, leisure and recreation compared with
provide consent individual therapy, and rehabilitation control participants.
services such as group therapy and
psychoeducation No group differences were found on
any ILSS subscales other than Leisure
and Recreation. The lack of differences
in these areas may reflect the limited
attention to these skill areas in the
HOPES program.
Rus-Calafell et al. (2013) Level I Intervention • SCIP The intervention group showed signifi-
Social skills training targeting behav- • PANSS cant improvements in psychopathology
RCT iors including social perception, social • Assertion Inventory (i.e., negative symptoms), social discom-
N = 31 (19.5% women; M age = information processing, responding and • SISST fort, social cognition, social withdrawal,
39 yr). sending skills, affiliative skills, interac- • SSIT interpersonal communication, and QOL
tional skills, and behavior governed by • SFS (i.e., mental health) compared with
Intervention group, n = 13. social norms plus TAU if desired • SF–36 the control group. However, positive
self-statements were not maintained at
Control group, n = 18. Control follow-up.
TAU including case management, medi-
cation adherence, psychotherapy, leisure
phrenia or schizoaffective disorder, age
engagement, and family support
18–55 yr, able to participate in group
therapy, no psychiatric hospitalization
within past 6 mo
(Continued)
A14

Tungpunkom et al. (2012) Level I Intervention • PANSS No significant differences in outcomes

Life skills training programs includ- • SANS of life skill performance, mental state,
Systematic review ing interpersonal skills, grooming and • POMS or QOL were found between groups
N = 7 RCTs. personal hygiene, stress management, • Future Outlook Inventory receiving life skills training and control
nutrition, finances, and time manage- • HAM–D groups. The authors indicated that
N = 483 participants (2 studies ment skills, ranging from 7 to 24 wk • Nurses’ Observation Scale for outcome data for these studies may lack
addressed only women; 1 addressed Inpatient Evaluation sufficient power to detect a treatment
only men; 4 mixed men and women; Control • SSPI effect.
M age = 32–50 yr). Access to OT, peer support, and stan- • Medication Management Abilities
dard care (recreation, art) Assessment Overall quality of evidence was low;
Intervention group, n = 256. large RCTs are needed.
• SSPA
Control group, n = 227. • UPSA
• Zung Self-Rating Depression Scale
Inclusion criteria: Randomized or • General Quality of Life Inventory
quasi-randomized controlled trials;
participants ages 18–60 yr diagnosed
(using any criteria) with chronic mental
illness
Cognitive-Based Interventions
Briki et al. (2014) Level I Intervention • Disorder awareness: Scale to Assess Intervention participants demonstrated
TAU plus metacognitive training Unawareness of Mental Disorder some improvements in insight, social
RCT sessions including education on • Symptoms: PANSS, Psychotic functioning, and QOL and decreases in
N = 50 (80.5% men; M age = 41 yr). medication, relationships, work, lei- Symptom Rating Scales, Calgary symptoms, but no changes achieved
sure, symptom management, chang- Depression Scale for Schizophrenia significance.
Intervention group, n = 25. ing beliefs, empathy, hasty judgment, • QOL: QLS
mood, and self-esteem, delivered by
psychiatrists, psychiatric nurses, and
Inclusion criteria: Age 18–65 yr, diagno- physician or psychologist interns, 1-hr
sis of schizophrenia spectrum disorder sessions 2×/wk for 8 wk
(DSM–IV–TR), persistent hallucinations
Control
or delusion
TAU plus supportive therapy providing
verbal interactions to express them-
selves and listen to each other, delivered
by psychiatrists, psychiatric nurses, and
physician or psychologist interns, 1-hr
sessions 2×/wk for 8 wk
(Continued)
A15

Bucci et al. (2013) Level I Intervention • QOL: QLS The intervention group showed
Neurocognitive individualized training • Symptoms: PANSS, 4 cognitive improved cognitive skills and inter-
RCT based on a computer-assisted cogni- domains (assorted) personal relationships; the control
N = 72 (80% men; M age = 38.3 yr). tive rehabilitation program, RehaCom, • 1st day: CPT–AX, Picture Memory group showed no or negative effect on
addressing attention and concentra- and Interference Test, TMT, Audio cognition but improvement on the QLS
Intervention group, n = 32. tion, verbal memory, memory for faces, Verbal Learning Task, Category Instrumental Role subscale.
logical thinking, shopping, and day Instances, WCST
planning, delivered by social workers, • 2nd day: real-world functioning
Inclusion criteria: Age 18–60 yr; a psychologist, and a psychiatrist, 1-hr • Psychopathological evaluation
diagnosis of schizophrenia or schizoaf- individual sessions 2×/wk for 6 mo
fective disorder confirmed by the Mini
Control
International Neuropsychiatric Interview
Individualized social training targeting
Plus; no hospitalization, symptom
important social cognition, including
exacerbation, or changes in medication
recognizing and expressing feelings,
in past 3 mo; ≥5 yr of education; no
apologizing, and sharing fears, with
medical, neurological, or developmental
modeling, feedback, and behavioral
illness involving severe or long-lasting
rehearsal, 2-hr group sessions per week
disability; no alcohol or drug abuse;
for 6 mo
willingness to participate (Italy)
Cavallo et al. (2013) Level I Intervention • Neuropsychological assessment: Limited evidence was found for the
Standard psychiatric management plus BACS, Tower of London Test (EF) effectiveness of intensive structured
RCT pilot cognitive rehabilitation using Brainer • Clinical assessment: PANSS computer-based cognitive train-
N = 10 (70% men; age range = 18–56 software (www.brainer.it) consisting of • Social cognition: Social Contexts and ing. Trends (p = .03) were found for
yr). 72 exercises covering multiple cognitive Nonsocial Contexts comic strip task, improved cognitive domains and social
functions with increasing complexity in Reading the Mind in the Eyes task cognition abilities with cognitive train-
Intervention group, n = 5. the presence of a psychiatric therapist, • Function: Frontal Assessment ing. Study interpretation is limited by
30-min computer-based sessions 3×/wk Battery, GAF, Personal and Social the small sample size.
for 12 consecutive weeks Performance Scale
Inclusion criteria: Adults recruited from
Control
a psychiatric day center, diagnosis of
Standard psychiatric management plus
schizophrenia spectrum disorder, stable
unstructured computerized intervention,
with medication (Italy)
such as reading newspapers, playing
games or solving puzzles, or explor-
ing sites of interest in the presence
of a rehabilitation therapist, 30-min
computer-based sessions 3×/wk for 12

consecutive weeks
A16
(Continued)

Chan et al. (2012b) Level I Intervention Sleep measures: HRSD, total sleep Both intervention groups demonstrated
Group 1: CBT delivered by a clinical time, sleep onset latency, wake time improvement in sleep. Intervention
RCT, 3 groups psychologist, 10 sessions plus home after sleep onset Group 2 demonstrated greater improve-
N = 75 (78% women; M age = 46.6 yr, assignments ment in sleep quality and time.
range = 28–62 yr). Group 2: Dejian mind–body intervention
Intervention Group 1, n = 25. based on Shaolin medical principles,
including Shaolin qigong exercises and
Intervention Group 2, n = 25. food recommendations, delivered by
clinical psychologists, 10 sessions plus
home assignments
Inclusion criteria: Adults with MDD and
Control
≥1 sleep problem
Wait list
De Silva et al. (2013) Level I Intervention • Social functioning measures of core Findings included mixed outcomes and
Psychosocial interventions identified domains of occupation, education, a wide variety of interventions.
Systematic review and meta-analysis as nonpharmacological or physical household role, marital functioning,
parental role, leisure and recreational A moderate positive effect of psychoso-
N = 24 studies (4 studies included only intervention, included psychotherapies cial interventions on social functioning
women; 2 studies included only men). such as CBT, social skills training, and activities, and self-care
alternative therapies including exercise • SF–36 was found in people with depression,
Inclusion criteria: RCTs conducted in and art therapy; intervention duration • SFS but the effect was not as positive for
low- and middle-income countries mea- ranged from 3 mo to 12 mo • Lambert’s Outcome Questionnaire people with schizophrenia because of
suring social functioning using a valid • Uganda Functional Impairment risk of bias in studies.
tool and quantitative assessment; psy- Control Score
chosocial intervention to improve social TAU or placebo • GAF
functioning of people with depressive • SOFS
disorders or schizophrenia vs. TAU • GAS
• WHO–DAS–II
• SDSS
• Brief Disability Questionnaire
• Sex-specific 9-item questionnaire
Farhall et al. (2009) Level I Intervention • Symptoms: PANSS No group differences were found.
TAU + CBT for Psychosis, a manualized • Anxiety: Hospital Anxiety and
RCT recovery program for creating individualized Depression Scale
goals and interventions addressing
(Continued)
A17

N = 94 (57.4% men; M age = 32–33 everyday coping, working with symp- • Community function: Working
yr). toms, understanding own experience of Alliance Inventory, Life Skills Profile
psychosis, strengthening adaptive view
Inclusion criteria: Self-selected partici- of self, personal and emotional issues,
pants with diagnosis of schizophrenia, comorbid disorders, relapse prevention, and
schizoaffective disorder, delusional dis- family or social integration, delivered by
order, or mood disorder with psychotic psychologists
features at 2 community mental health
clinics Control
TAU
Gil Sanz et al. (2009) Level I Intervention • WHO–DAS–II The intervention resulted in improved
Integrated Psychological Therapy • Direct Digits of the Integrative personal care, daily activities, and social
RCT pilot program, a social cognition training Program of Neuropsychological perception and interpretation, but not
N = 14 (50% men; age = 24–50 yr). program with modules on emotion rec- Exploration of the Barcelona Test improved emotion recognition, com-
ognition, cognitive differentiation, social • PANSS pared with the control condition.
Intervention group, n = 7. perception, verbal communication, • Facial recognition using NimStim
social skills, and problem solving Face Stimulus Set of 30 facial emo-
tion photographs
Control • Spanish Social Perception Scale
TAU
of schizophrenia attending a psychoso-
cial rehabilitation center
Granholm et al. (2009) Level I Intervention • ILSS Both interventions increased social
Group CBSST, 6 weekly 2-hr sessions • Revised Social Anhedonia Scale interest and had some effect on social
RCT attitudes, suggesting that group interac-
Control tion is beneficial.
N = 79 (30 middle-aged or older, 49 Goal-focused supportive contact, weekly
age ≥18 yr). group sessions
Intervention group, n = 39 (46.2% men;
M age = 51.9 yr).
Control group, n = 40 (67.5% men; M

age = 48.9 yr).
Inclusion criteria: Participants with

schizophrenia from other ongoing stud-
ies participating in group therapy, age
≥18 yr, no prior exposure to social skills

training or CBT in past 5 yr
A18
(Continued)

Granholm et al. (2014) Level I Intervention: • ILSS The intervention group showed signifi-
CBSST group therapy with modules • CMT cant improvements in levels of function-
RCT focused on cognition, social skills, and • MASC ing, negative symptoms, and defeatist
N = 149 (66.4% men; M age = 41.35 problem solving, 2-hr weekly group ses- • Psychosocial Rehabilitation Toolkit performance attitudes compared with
yr). sions plus individual sessions • PANSS the control group.
• SANS
Inclusion criteria: Age ≥18 yr, diagnosis Control • BDI–II Both groups improved in social compe-
of schizophrenia or schizoaffective disor- Contact control consisting of GFSC • DPAS tence and positive symptoms.
der, able to provide informed consent group therapy with a focus on setting
and achieving functional goals, 2 hr/wk
plus individual sessions
Granholm et al. (2013) Level I Intervention • ILSS Both groups improved in symptom dis-
CBSST with modules including thought • DPAS tress, motivation, self-esteem, and life
RCT challenging (changing cognitive beliefs), • Symptoms: PANSS, SANS, BDI–II, BAI satisfaction. People with more defeatist
N = 79 (27 veterans, 52 nonveterans; social skills training (communication • Diminished Expression attitudes may benefit more from cogni-
55% men; M age = 55 yr). skills and role-playing interactions with • Diminished Motivation tive–behavioral intervention.
professionals, family, friends, and room- • Self Esteem Rating Scale
Inclusion criteria: Community-dwelling mates), and problem-solving skills, 36 • Life Satisfaction Index
adults with schizophrenia or schizoaffec- 2-hr weekly group sessions over 9 mo • CMT for Social Skills changes
tive disorder, age >45 yr
Control
GFSC focused on setting and achieving
functional goals related to living, working,
learning, and socializing, including psy-
choeducation, empathy, nondirective rein-
forcement of health, coping and symptom
management, and group discussion, pro-
vided by same therapists as intervention in
36 2-hr weekly group sessions over 9 mo
Hasson-Ohayon et al. (2014) Level I Intervention • Emotion recognition: FEIT Emotion recognition in the SCIT group
SCIT plus social mentoring to establish • Theory of mind: faux pas test improved significantly. Both groups
RCT meaningful goals and steps toward goal • Attributional bias: AIHQ improved in theory of mind and social
N = 55 (56% men; M age = 38.5 yr). achievement, 3 weekly meetings in per- • Social functioning: SFS Social engagement.
son plus 2 additional weekly meetings Engagement and Interpersonal
Inclusion criteria: Living in community for SCIT by trained interveners Communication subscales
settings; diagnosis of schizophrenia,
schizoaffective disorder, depression, or Control
bipolar disorder; fluency in Hebrew; able Social mentoring only, 3 weekly meet-
to provide informed consent (Israel) ings in person
A19
(Continued)

Horan et al. (2011) Level I Intervention • Social cognition: FEIT; Managing The SCST group demonstrated greater
Group 1: SCST, a group intervention Emotions (subtest of Mayer–Salovey– improvements over time than com-
RCT that targets emotional processing, social Caruso Emotional Intelligence Test); parison groups in the social cognitive
N = 68 (88% men). perception, attributional bias, and men- Half-Profile of Nonverbal Sensitivity; domain of emotional processing, includ-
talizing, 24 sessions over 12 wk AIHQ; Awareness of Social Inference ing improvement on measures of facial
Intervention Group 1, n = 16 (M age = Test Part 3 affect perception and emotion manage-
51 yr). Group 2: Computerized neurocognitive • Cognitive: NIMH–MATRICS, ment. Social cognition did not change.
remediation, 24 sessions over 12 wk Consensus Cognitive Battery
Intervention Group 2, n = 19 (M age = For the hybrid SCST and neurocognitive
Group 3: Hybrid treatment combining • Performance skills: UPSA
46.6 yr). rehabilitation intervention, participants’
elements of SCST and neurocognitive • Symptoms: BPRS, SANS
functional capacity trended better on
Intervention Group 3, n = 14 (M age = remediation, 24 sessions over 12 wk the MASC but not on the UPSA.
50.4 yr).
Control Limitations were noted in outcome
Control group, n = 19 (M age = 45.1 yr). Standard illness management skills
measures.
training, 24 sessions over 12 wk
Inclusion criteria: Met DSM–IV criteria
for schizophrenia, schizoaffective dis-
order, delusional disorder, or psychosis
not otherwise specified (not secondary
to substance use disorder); clinically
stable (no psychiatric hospitalizations
in past 2 mo, same antipsychotic
medication for past 6 wk, no medication
changes anticipated for next 3 mo)
Hsu et al. (2015) Level II Intervention • HAM–D A significant group difference in

CBT–I, 90-min group sessions delivered • Dysfunctional Beliefs and Attitudes PSQI scores was observed at 1-mo
Parallel-group design with random by a nurse experienced with CBT, 1×/ About Sleep follow-up but not at completion of the
assignment of convenience sample wk for 6 wk • Presleep Arousal Scale intervention.
N = 24 (54.2% men; M age = 52 yr). • Sleep Hygiene Practice
Control • PSQI
Intervention group, n = 13. Insomnia health education manuals
Inclusion criteria: Inpatients in psychi-

atric ward with MDD, single-episode,
recurrent-episode, or neurotic depres-
sion; age ≥18 yr; received entire dura-

tion of treatment; score >14 on HAM–D;
taking benzodiazepines for insomnia;
A20
taking antidepressant (Taiwan)
(Continued)

Kidd et al. (2014) Level III Intervention • SOFS Significant improvements were found in
CAT, a manualized intervention that • MCAS adaptive functioning, psychiatric symp-
Repeated measures uses compensatory strategies involving • GAS toms, and goal attainment.
N = 24 (70.8% men; M age = 40 yr). behavioral, neuropsychological, and • BPRS
OT principles with case management This useful intervention might sustain its
Inclusion criteria: Chart diagnosis of follow-up impacts in an abbreviated format with
schizophrenia or schizoaffective disor- support from existing case managers.
der, age ≥18 yr, significant challenges Control
in psychosocial functioning, stable living No control
circumstance for ≥3 mo (Canada)
Matsunaga et al. (2010) Level III Intervention • GAF Participants improved on all measures
Group CBT, 12 weekly 90-min sessions • SF–36 of psychosocial functioning and mood
Repeated measures • HRSD symptoms; 20 maintained improvements
Control • Dysfunctional Attitudes Scale at 12 mo.
N = 43 (55.8% men; M age = 41.3 yr). No control • Automatic Thought
Inclusion criteria: Outpatients with MDD, Questionnaire–Revised
able to participate in group CBT for 12 wk,
HRSD score of ≥8, defined as treatment
resistant at Stage 2 or greater (Japan)
Michalak et al. (2015) Level I Intervention • HAM–D MBCT was more effective than TAU at
Group 1: CBASP: behavioral, cognitive, • BDI one of the treatment sites. CBASP was
RCT and interpersonal treatment strategies • Social Adaptation Self-Evaluation significantly more effective than TAU in
N = 106. developed within group by members and Scale reducing depression.
therapists; situational analysis adminis- • SF–36
Intervention Group 1, n = 35 (62.9% tered by clinical psychologist and certified Both MBCT and CBASP had small to
women; M age = 50.2 yr). CBASP therapist; 2 individual treatment medium effects on social functioning
sessions for transference hypotheses fol- and QOL.
Intervention Group 2, n = 36 (58.3%
lowed by 8 weekly 2.5-hr group sessions
women; M age = 48.4 yr).
with ≤6 persons in group.
Control group, n = 35 (65.7% women;
Group 2: MBCT: sitting meditation; yoga;
M age = 54 yr).
homework of mindfulness practice and
Inclusion criteria: Major depression generalization; cognitive–behavioral skills;
episode with symptoms lasting >2 yr administered by clinical psychologist and
without remission certified MBCT therapist; preclass individ-
ual interview followed by 8 weekly 2.5-hr
sessions with ≤6 persons in group.
Control
TAU (individual treatment with either
A21
psychiatrist or psychotherapist)
(Continued)

Poletti et al. (2010) Level I Intervention • Cognitive: BACS, WCST The intervention produced significant
Standard rehabilitation treatment plus • CPT changes in executive function, attention,
RCT cognitive remediation therapy consisting • Q LS and psychomotor coordination.
N = 100 (60% men; M age = 34 yr). of exercises targeting cognitive areas
including (but not limited to) verbal The intervention group showed signifi-
Intervention group, n = 58. memory, verbal fluency, EF, working cant improvement in daily functioning,
memory, and attention and non- including self-directedness and inter-
Control group, n = 42. personal relations, at 6- and 12-mo
domain-specific exercises, 1-hr sessions
3×/wk for 12 wk follow-up.
phrenia, treated with stable dose of
Control
same antipsychotic therapy ≥6 mo,
2 extra hours of standard rehabilitation
responsive and clinically stable, able to
treatment and 1 hr/wk of non-domain-
participate in a rehabilitation program
specific activity for 12 wk, plus placebo
Roberts et al. (2014) Level I Intervention • PANSS The intervention group demonstrated
SCIT including psychoeducation, skill • Schizophrenia Cognition Rating Scale modest improvement in social function-
RCT practice, strategy games, rehearsal, and • FEIT ing, negative symptoms, and hostile
N = 66 (66.7% men; M age = 39.5 yr). homework assignments with a practice • Hinting Task attributional bias. Post hoc analysis
partner, 1-hr sessions over 20–24 wk • Social Inference–Enriched subtest of implied that SCIT may be more effective
Intervention group, n = 33. the Awareness of Social Inference when provided in a greater dosage.
Control Task
Control group, n = 33. TAU consisting of a combination of ser- SCIT was not better than TAU in pro-
• AIHQ–A
vices including pharmacotherapy, case • SSPA ducing improvement in social cognitive
Inclusion criteria: Outpatients with schizo-
management, and individual and group • Global Social Functioning Scale domains.
phrenia or schizoaffective disorder; age
psychotherapy • QLS–Social and QLS–Work
25–60 yr, difficulties interacting with others
based on Interaction subscale of the SFS
Sánchez et al. (2014) Level I Intervention • PANSS The intervention group showed improve-
REHACOP, a new-generation multi- • GAF ments in GAF and social competence
RCT dimensional cognitive remediation • CGI and reductions in negative symptoms
N = 84 (76.2% men; M age = 35 yr). program with a specific emphasis on the • WHO–DAS and functional disability; no specific
implementation of learned skills in ADLs • Stroop color test, word–color and mention was made of ADLs.
Intervention group, n = 36. in their real environment led by a neuro- interference scores
psychologist, 3×/wk over 3 mo • Trails A The intervention group improved sig-
Control group, n = 48. nificantly compared with the control
• Symbol Digit, Digit Forward, and Digit
Control Backward of the WAIS–III group according to significant Group ×
Inclusion criteria: Met DSM–IV–TR diag-
Activities (drawing, reading the daily Time interactions for processing speed,
nostic criteria for schizophrenia • Hopkins Verbal Learning Test

news, and constructing objects using • Semantic and Phonological Fluency working memory, verbal learning and
different materials) in a group format subtests from the Barcelona Test memory, verbal fluency, and EF.
A22
• Accentuation Reading Test
(Continued)

Tas et al. (2012) Level I Intervention Primary The intervention group significantly
Family-assisted SCIT with a participant- • QLS improved in QOL, social functioning,
RCT identified social cognition training part- • SFS and social cognition compared with
N = 49 (57.9% men; M age = 34 yr). ner, 1×/wk for 14 wk Secondary the control group. All QLS subscale and
• Social Cognition domains total scores were significantly higher in
Intervention group, n = 22. Control the intervention group.
Social stimulation consisting of half-day • PANSS
Control group, n = 27. activities promoting socialization (e.g., • BCIS
watching a movie, having a chat, 1× • TMT
Inclusion criteria: Diagnosis of schizophre- • Wechsler Memory Scale–Revised
every 3 wk for 14 wk
nia, clinically stable (no psychiatric hos-
pitalization in past 6 mo, antipsychotic
medication stable for 6 mo), receiving
2nd-generation antipsychotic medication
Taylor et al. (2015) Level I Intervention • Sleep diary (e.g., bedtime, rise time) CBT–I resulted in significant improve-
Traditional CBT–I teaching sleep restric- • ISI ment in sleep as indicated by ISI score,
RCT tion and stimulus control, with an added • Patient Health Questionnaire–9 sleep onset latency, and wake after
N = 23 (91% women; M age = 50.5 yr). medication reduction module • Generalized Anxiety Disorder–7 sleep onset. No changes in depression,
• SF–36 anxiety, or QOL were found.
Intervention group, n = 13. Control
TAU (medication treatment with
Control group, n = 10. psychiatrist)
Inclusion criteria: Report of continued
symptoms of insomnia despite use of sleep
medication, receiving outpatient treatment
for comorbid psychiatric diagnoses
Taylor et al. (2016) Level I Intervention • Social goal achievement Intervention participants improved
SCIT addressing emotional perception, • FEIT significantly in facial affect recognition
RCT ability to understand another’s inten- • Hinting Task compared with the control group
N = 36 (100% men; M age = 40 yr). tions, and generalization of skills, 16 • AIHQ (p < .001).
biweekly 45-min sessions • BCIS
Intervention group, n = 21. More than half of participants in SCIT
Control indicated strong agreement that they
Control group, n = 15. TAU had achieved their identified social goal.
Inclusion criteria: Age 18–65 yr, suf-
ficient English to consent to research,
ability to complete assessments and
engage with intervention, diagnosis of
A23
schizophrenia spectrum disorder, dif-

ficulties with social functioning
(Continued)

Velligan et al. (2009) Level I Interventions • SOFS The intervention groups showed short-
Both interventions (CAT and GES) are • BPRS–Expanded term improvements in global functional
RCT manualized programs that target treat- • Negative Symptom Assessment outcomes compared with the control
N = 113. ment and medicine adherence, orienta- • MCAS group.
tion and scheduling, and grooming and • Comprehensive behavioral, neuropsy-
Intervention Group 1 (CAT), n = 36 hygiene using different levels of adapta- chological, functional, and environ- CAT resulted in improvements in the
(50% men; M age = 41 yr). tions and environmental supports; CAT mental assessments targeted behaviors of orientation and
targets adaptations based on cognitive hygiene.
Intervention Group 2 (GES), n = 38
impairments, whereas GES uses generic
(50% men; M age = 42 yr).
supports.
Control group, n = 39 (51.3% men;
Control
M age = 40 yr).
TAU
Inclusion criteria: Diagnosis of schizophre-
nia or schizoaffective disorder (Structured
Clinical Interview for DSM–IV ), age
18–60 yr, being treated with atypical
antipsychotic medication (not clozapine),
no hospital admissions in past 3 mo,
stable living environment for past 3 mo
Yip et al. (2013) Level II Intervention • Violent attitudes, coping skills, social The intervention group improved in
Cognitive-based R&R2MHP manualized problem solving, reaction to provoca- social problem solving and coping pro-
Nonrandomized controlled trial program delivered by a trained multidis- tion, disruptive behavior, and social cesses and decreased disruptive behav-
N = 59 (100% men; M age = 38 yr). ciplinary team, 16 weekly 90-min ses- function ior and violent attitudes. Most measures
sions for groups of 5–8 with additional • MVQ indicated significant improvements
Intervention group, n = 30. weekly individual mentoring sessions • Novaco Anger Scale and Provocation (p = .05–.001) for those who com-
Inventory pleted the intervention. No significant
Control group, n = 29. Control • Ways of Coping Scale differences found on the SPSI–RS or
Inclusion criteria: Violent offenders
TAU with intention to treat; not allowed • SPSI–RS Machismo scale of the MVQ.
to participate in cognitive skills interven- • Disruptive Behavior and Social
from 2 high-security forensic hospitals,
tion groups similar to R&R2MHP Problems Scale
referred to participate by their clinical
team, history of SMI (schizophrenia,
schizoaffective, or bipolar disorder),
history of violent offending or antisocial
behavior, no previous experience with
intervention, proficient in English (United
Kingdom)
(Continued)
A24

Technology-Supported Interventions
Kaplan et al. (2014) Level I Intervention • Parenting perceptions of competence The intervention group showed sig-
Online participation in a peer support • Healthy Families Parenting Inventory nificant improvement in parental stress
RCT listserv with a provider and a mother • Family Coping Inventory but no significant changes in parental
N = 60 (100% women; M age = 37 yr). with lived experience addressing top- • Medical Outcome Study efficacy or social support compared with
ics including (but not limited to) child • Social Support Survey the control group.
Inclusion criteria: Mothers age ≥18 yr, development, stress reduction, mental
diagnosis of mood or schizophrenia health, and parenting skills based on
spectrum disorder, current primary or CBT techniques, weekly 30-min sessions
shared custody and serving as caretaker over 3 mo
of ≥1 child age ≤18 yr, Internet access,
fluent in English Control
Access to a website with educational
fact sheets about maintaining a healthy
lifestyle
Lin et al. (2008) Level II Intervention • Depression knowledge Intervention participants showed a
Interactive computerized psychoeduca- • BDI decreased (nonsignificant) incidence of
Quasi-experimental pre–post tion system delivered by nurses • Compliance Behavior Assessment medication noncompliance compared
N = 32 (28.1% men; M age = 36 yr, Scale with control participants.
Control • Adherence to medications
range = 19–54 yr). Pamphlets
Inclusion criteria: Depression, willing-

ness to participate (Taiwan)
Pijnenborg et al. (2010) Level II Intervention Primary Mean success percentages over all goal
Text message prompts (2 per goal) sent • Percentage of goals achieved categories (i.e., appointments, medica-
Nonrandomized 2 groups controlled to participants over 7 wk plus TAU tion, training program, activities, inhibi-
N = 62 (79.0% men; M age = 28.8 yr). tion) for both groups were 47% during
(Continued)
A25

Intervention group, n = 33. Control Secondary baseline, 62% during intervention, and
TAU • Groninger Intelligence Test 40% at follow-up.
Control group, n = 29. • Client Motivation for Therapy Scale
• RSES Results were significant for mean per-
Inclusion criteria: Diagnosis of schizo- centage success during interventions.
phrenia or Axis II diagnosis with psy- • SFS
chotic symptoms, observed limitations in • PANSS Performance dropped to baseline after
goal-directed behavior in daily life withdrawal of the text messages.
Note. ADLs = activities of daily living; AIHQ–A = Ambiguous Intentions Hostility Questionnaire–Ambiguous Situations; BACS = Brief Assessment of Cognition in Schizophrenia; BAI = Beck Anxiety Scale; BCIS = Beck
Cognitive Insight Scale; BDI = Beck Depression Inventory; BPRS = Brief Psychiatric Rating Scale; CAT = Cognitive Adaptation Training; CBASP = Cognitive Behavioral Analysis System of Psychotherapy; CBSST = cognitive–
behavioral social skills training; CBT = cognitive–behavioral therapy; CBT–I = cognitive–behavioral therapy for insomnia; CGI = Clinical Global Impression Scale; CMT = Comprehensive Module Test; CPT = Continuous
Performance Test; CPT–AX = AX–Continuous Performance Test; DAI = Drug Attitude Inventory; DPAS = Defeatist Performance Attitude Scale; DSM = Diagnostic and Statistical Manual of Mental Disorders; EF = execu-
tive function; FEIT = Face Emotion Identification Test; GAF = Global Assessment of Function; GAS = Global Assessment Scale; GES = Generic Environmental Supports; GFSC = goal-focused supportive contact; HAM–D =
Hamilton Rating Scale for Depression; HIV = human immunodeficiency virus; HoNOS = Health of the Nation Outcome Scale; HOPES = Helping Older People Experience Success; HRSD = Hamilton Psychiatric Rating Scale
for Depression; IADLs = instrumental activities of daily living; ILSS = Independent Living Skills Survey; ISI = Insomnia Severity Index; M = mean; MASC = Maryland Assessment of Social Competence; MATRICS–NIMH =
Measurement and Treatment Research to Improve Cognition in Schizophrenia–National Institute of Mental Health; MBCT = mindfulness-based cognitive therapy; MCAS = Multnomah Community Ability Scale; MDD =
major depressive disorder; Mdn = median; MOHOST = Model of Human Occupation Screening Tool; MVQ = Maudsley Violence Questionnaire; OSA = Occupational Self-Assessment; OT = occupational therapy/thera-
pist; PANSS = Positive and Negative Syndromes Scale; POMS = Profile of Mood States; PSQI = Pittsburg Sleep Quality Index; QLS = Quality of Life Scale; QOL = quality of life; RCT = randomized controlled trial; RSES =
Rosenberg Self-Esteem Scale; SANS = Scale for the Assessment of Negative Symptoms; SBS = Social Behavior Schedule; SCIP = Screen for Cognitive Impairment; SCIT = Social Cognition and Interaction Training; SCST
= Social Cognitive Skills Training; SDSS = Social Disability Schedule; SFS = Social Functioning Scale; SF-36 = 36-Item Short Form Health Survey; SISST = Social Interaction Self-Statement Test; SMI = serious mental illness;
SOFS = Social and Occupational Functioning Scale; SPSI–RS = Social Problem-Solving Inventory–Revised: Short; SSIT = Simulated Social Interaction Test; SSPA = Social Skill Performance Assessment; SSPI = Social Skills for
Psychiatric Inpatients; SSRI = selective serotonin reuptake inhibitor; TAU = treatment as usual; TMT = Trail Making Test; Trails A = Trail Making Test Part A; UPSA = University of California, San Diego, Performance-based
Skills Assessment; WAIS = Wechsler Adult Intelligence Scale; WCST = Wisconsin Card Sorting Test; WHO–DAS = World Health Organization Disability Assessment Schedule; WHOQOL = World Health Organization Quality
of Life assessment; WHOQOL–BREF = abbreviated WHOQOL.
This table is a product of AOTA’s Evidence-Based Practice Project and the American Journal of Occupational Therapy. Copyright © 2018 by the American Occupational Therapy Association. It may be freely reproduced for
personal use in clinical or educational settings as long as the source is cited. All other uses require written permission from the American Occupational Therapy Association. To apply, visit www.copyright.com.
Source. D’Amico, M. L., Jaffe, L. E., & Gardner, J. A. (2018). Evidence for interventions to improve and maintain occupational performance and participation for people with serious mental illness: A systematic review
(Suppl. Table 1). American Journal of Occupational Therapy, 72, 7205190020. https://doi.org/10.5014/ajot.2018.033332
Suggested citation: Noyes, S., & Lannigan, E. G. (2019). Occupational therapy practice guidelines for adults living with serious mental illness (Table A.1). Bethesda, MD: AOTA Press.
A26
Table A.2. Risk-of-Bias Analysis for Intervention Studies Included in the Systematic Review of Interventions to Promote ADLs and IADLs, Rest and Sleep,
Leisure, and Social Participation for Adults Living With SMI
Blinding of Outcome Incomplete Outcome Data

Selection Bias Blinding of Assessment (Detection Bias) (Attrition Bias) Selective
Participants Reporting
Random Sequence Allocation and Personnel Short Term Long Term (Reporting
Citation Generation Concealment (Performance Bias) Patient-Reported Outcomes (2–6 wk) (>6 wk) Bias)
Level I Evidence
Bartels, Pratt, Mueser, + + + + + + +

Forester, et al. 2014
Berget et al. (2008) + + – – + + +
Briki et al. (2014) + + + + + + +
Bucci et al. (2013) ? ? – – – – +
Carta et al. (2014) + + – + + + +
Cavallo et al. (2013) + ? ? + + + +
Chan et al. (2012b) + + + + ? ? +
Chen et al. (2015) + + + + + + +
Chien et al. (2016) + + −/+ + ? + +
Chu et al. (2009) + – – + + + +
Cook et al. (2009) + + ? + + + +
Farhall et al. (2009) + – – + + + +
Gil Sanz et al. (2009) + ? ? ? ? ? +
Granholm et al. (2009) – – – – – – +
Granholm et al. (2013) + – −/+ + + + +
Granholm et al. (2014) + + + + + + +
Hasson-Ohayon et al. + – – – – – +
(2014)
A27
(Continued)
Leisure, and Social Participation for Adults Living With SMI (cont.)

Horan et al. (2011) + + ? ? + + −
Kaplan et al. (2014) + ? + + + + +
Levitt et al. (2009) + ? + + + + +
Lin et al. (2013) + ? ? – ? + +
Michalak et al. (2015) + + + ? + + +
Mueser et al. (2010) + + −/+ + + + +
Poletti et al. (2010) + + + + – – ?
Rethorst et al. (2013) ? ? ? + ? ? +
Roberts et al. (2014) ? ? −/+ ? + + +
Roldán-Merino et al. + ? ? ? + + +
(2013)
Rus-Calafell et al. (2013) + ? ? ? ? ? +
Salyers et al. (2014) + ? ? −/+ ? ? +
Sánchez et al. (2014) + + + + ? + +
Štrkalj-Ivezic’ et al. (2013) + ? ? + ? ? +
Swildens et al. (2011) + + + + + + +
Tas et al. (2012) + + + + + + +
Tatsumi et al. (2012) + ? ? + + + +

Taylor et al. (2015) + ? ? ? + + +
Taylor et al. (2016) + NA ? + + ? +
A28
(Continued)
Leisure, and Social Participation for Adults Living With SMI (cont.)

vanderVoort et al. (2015) + – – – ? ? +
Velligan et al. (2009) ? ? + + ? ? +
Level II Evidence
Fitzgerald (2011) – – – – – – +
Hsu et al. (2015) – – ? ? + + +
Katz & Keren (2011) – – – – + + +
Lin et al. (2008) – – – – ? ? +
Pijnenborg et al. (2010) – – – – + + +
Yip et al. (2013) – – – – – – +
Level III Evidence
Clark et al. (2015) – – – – – – +
Helfrich & Chan (2013) – – ? ? ? ? +
Kidd et al. (2014) – – – – + +
Lindström et al. (2012) – – – – + + +
Matsunaga et al. (2010) – – – – + + +
Note. Categories for risk of bias are as follows: + = low risk of bias; ? = unclear risk of bias; – = high risk of bias. NA = not applicable.
Risk-of-bias table format adapted from “Assessing Risk of Bias in Included Studies,” by J. P. T. Higgins, D. G. Altman, and J. A. C. Sterne, in Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0), by J. P. T.
Higgins and S. Green (Eds.), 2011, London: Cochrane Collaboration. Retrieved from http://handbook-5-1.cochrane.org. Copyright © 2011 by The Cochrane Collaboration.
A29
Table A.3. Risk-of-Bias Analysis for Systematic Reviews Included in the Systematic Review of Interventions to Promote ADLs and IADLs, Rest and Sleep,
Leisure, and Social Participation for Adults Living With SMI
Duplicate Comprehen Status of List of Included/ Characteristics

A priori Study sive Literature Publication Excluded of Included Quality of Studies Quality Methods Used to Likelihood of Conflict
design Selection/Data Search as Inclusion Studies Studies Assessed and Assessment Used Combine Results Publication of Interest
Citation included? Extraction? Performed? Criteria? Provided? Provided? Documented? Appropriately? Appropriate? Bias Assessed? Stated?
Almerie et al. (2015) + + + + + + + + + + +
Batista et al. (2011) + + + + + + + ? + – –
Bond & Anderson + + + + +/– + + + + – +

(2015)
Cramer et al. (2013) + + + + + + + + + + +
De Silva et al. (2013) + + + + + + + + + + –
Gibson et al. (2011) + + + + +/– + + + + ? +
Pandor et al. (2015) + + + + + + + + + + +
Thomas et al. (2011) + – + + + + + + – – +
Tungpunkom et al. + + + ? + + + + + – +
(2012)
Walsh et al. (2014) + + + + + + + + + + –
Xia et al. (2013) + + + + + + + + + + +
Note. Risk-of-bias categories: + = low risk of bias; ? = unclear risk of bias; – = high risk of bias.
Risk-of-bias table format adapted from “Development of AMSTAR: A Measurement Tool to Assess the Methodological Quality of Systematic Reviews,” by B. J. Shea, J. M. Grimshaw, G. A. Wells, M. Boers, N. Anderson, C.
Hamel, . . . L. M. Bouter, 2007, BMC Medical Research Methodology, 7, p. 10. https://doi.org/10.1186/1471-2288-7-10
A30
Table A.4. Evidence Table for the Systematic Review of Interventions to Support Employment and Education for Adults Living With SMI

Arbesman & Logsdon Level I Intervention Varied across studies; all were targeted Strong evidence exists for the effective-
(2011) • Work programs: supported employ- toward effectiveness of intervention for ness of supported employment using IPS
Systematic review ment and VOC employment and education outcomes for in promoting competitive employment,
N = 46 studies. • Supported education programs adults with SMI especially when combined with cognitive
• Supported employment plus cognitive or social skills training. Supported educa-
Inclusion criteria: Level I–III studies pub- or social skills training tion programs emphasizing goal setting,
lished in English in a peer-reviewed jour- • Programs related to homemaking, par- skill development, and cognitive training
nal, participants with diagnosis of SMI enting, and environmental supports resulted in increased participation in edu-
aged 18–65, interventions within scope • Social and daily living skills cational pursuits.
of occupational therapy practice intervention
Areberg & Bejerholm Level I Intervention • IPS fidelity measure: Supported IPS had a positive effect on participants’
(2013) IPS Employment Fidelity Scale QOL, including a significant increase in
RCT • Occupational engagement: Profile of time-use-assessed occupational engage-
Control Occupational Engagement in People ment. At 18-mo follow-up, significant
N = 120. TVR With Severe Mental Illness differences between groups regarding
Intervention group, n = 60 (M age = 38, • Work motivation: Worker Role overall QOL, work motivation, and
47% male). Interview empowerment were noted in favor of the
• QOL: MANSA intervention group. In the control group,
Control group, n = 60 (M age = 38,
• Empowerment: Empowerment Scale positive significant changes in 1 QOL
65% male).
domain, general life satisfaction, were
Inclusion criteria: SMI (psychosis or long- shown between baseline and 18 mo.
term psychiatric disability), aged 20–65,
regular contact with mental health care, did
not work in previous year, expressed interest
in working, could communicate in Swedish,
attended an IPS informational meeting
Au et al. (2015) Level I Intervention Primary Although both groups demonstrated

ISE + CRT • Employment rate and job tenure: sustained improvements in vocational,
RCT Employment Outcome Checklist clinical, psychological, and neurocogni-
Control tive outcomes, no evidence indicates that
N = 90. ISE Secondary CRT facilitated further improvements
Intervention group, n = 45 (M age = • BPRS in these domains beyond gains associ-
35.4, 62.2% male). • GAF ated with the ISE stand-alone program.
• Personal Wellbeing Index–Adult Both groups showed improvement in
Control group, n = 45 (M age = 36.9, • RSES vocational outcomes, with competi-
64.4% male). • EF: WCST tive employment rates of 44%–56% at
• Processing speed, attention and 11-mo follow-up. Both groups showed
Inclusion criteria: Outpatients with
vigilance, visual learning and memory, improvement in all other vocational
schizophrenia or schizoaffective disorder
reasoning and problem solving, and outcomes, with a significant time trend
in Hong Kong, aged ≥18, scored <18 on
social cognition: MATRICS Consensus revealed in job tenure.
MMSE, not currently employed, competi-
Cognitive Battery
tive employment as vocational goal
• Verbal learning, working memory:
A31
Hong Kong List Learning Test
(Continued)
Table A.4. Evidence Table for the Systematic Review of Interventions to Support Employment and Education for Adults Living With SMI (cont.)

Bell et al. (2008a) Level I Intervention Vocational The intervention group showed sig-
NET + VOC, a 12-mo program consisting • Rate of competitive employment nificantly greater rates of competitive
RCT of intensive computer-based cognitive • Competitive employment hours employment after 2 yr compared with the
N = 72. training tasks and group interventions control group.
combined with a vocational program Nonvocational
Intervention group, n = 38 (lower com- delivered in 2 cognitively focused, staff- • Community functioning: QLS (higher Participants with higher community func-
munity function, n = 20, M age = 43.7, led groups per week—(1) work feedback community function, ≥39; lower com- tion showed significantly greater rates of
60% male; higher community function, group (attended by job specialists) munity function, <39) competitive employment after 2 yr com-
n = 18, M age = 40.0, 61% male). and (2) social information processing pared with those with lower community
group—and including CogRehab and function.
Control group, n = 34 (lower community
Sci-Learn cognitive remediation exercises For participants with higher community
function, n = 18, M age = 38.1, 50%
male; higher community function, Control function, no significant between-group
n = 16, M age = 36.2, 44% male). Community-based VOC services includ- differences were found for competitive
ing a hybrid transitional and supported employment.
employment program with essential For participants with lower community
of schizophrenia or schizoaffective dis-
features of IPS, weekly work groups, and function, the intervention group had
order, clinically stable (i.e., GAF >30; no
use of transitional funds for rapid job significantly higher rates of competitive
housing changes, psychiatric medication
placement in community-based sites employment and significantly higher
alterations, or psychiatric hospitalizations
in 30 days before intake) competitive employment hours than the
control group.
Bell et al. (2008b) Level I Intervention • Work hours Results support the hypothesis that
NET + VOC • Employment rates NET enhanced vocational outcomes.
RCT Participants in the intervention group
Control achieved more total hours worked during
N = 72. VOC the 12-mo follow-up period, had higher
Intervention group, n = 38 (M age = quarterly employment rates during the
42.0, 61% male). follow-up period, and achieved higher
cumulative rates of competitive employ-
Control group, n = 34 (M age = 37.2,
ment in the last 3 quarters. Control
47% male).
participants showed a steady decline in
Inclusion criteria: Outpatients with employment during Year 2.
schizophrenia or schizoaffective disor-
Participants who had received NET
der, clinically stable (i.e., GAF >30; no
were significantly better able to sustain
housing changes, psychiatric medication
employment throughout the 2nd year.
alterations, or psychiatric hospitalizations
in 30 days before intake)
(Continued)
A32

Bio & Gattaz (2011) Level I Intervention • PANSS VOC significantly improved participants’
VOC • Neuropsychological battery performance in cognitive measures of EF
RCT • QOL Questionnaire (concept formation, shifting ability, flex-
Control ibility, inhibitory control, and judgment
N = 112 (91 completed trial). Outpatient clinic follow-up and critical abilities).
Intervention group, n = 47 (M age =
21.3, 74.5% male).

84.1% male).
Inclusion criteria: Adult psychiatric out-
patients; diagnosis of schizophrenia;
aged >18; no hallucinations, delusions,
thought disorder, or catatonic behavior
during past 6 mo; stable treatment with
2nd-generation antipsychotic drugs dur-
ing past 6 mo; documented compliance
with treatment; unemployed during past
12 mo
Bond et al. (2008) Level I Intervention • Employment rates Average competitive employment rates
IPS • Days to 1st job across the 11 studies were 61% for IPS
Systematic review • Annualized weeks worked participants and 23% for control par-
Control • Job tenure in longest job held during ticipants. Average difference between
N = 11 studies. TAU or VOC follow-up period groups for percentage employed was
Inclusion criteria: RCTs of IPS model 38%.
examining longitudinal competitive
employment outcomes for people with Across studies, 134 (43.6%) of 307 IPS
SMI, participants randomly assigned participants and 53 (14.2%) of 374 con-
to ≥2 conditions (1 of which used a trol participants held competitive jobs.
high-fidelity IPS supported employment For the intervention groups, average time
model), control group or groups received to 1st job was approximately 4–5 mo;
either services as usual or some other average weeks worked was >2× that for
form of VOC besides IPS the control group.
Average job tenure for IPS participants

ranged from 37 wk in the Illinois study to
10 wk in the New Hampshire study.
(Continued)
A33

Bond, Kim, et al. (2015) Level I Intervention • Competitive employment: Dartmouth Over 12 mo, 31% of intervention par-
IPS Vocational Update Form ticipants vs. 7% of control participants
RCT • Psychiatric hospitalization admissions obtained a competitive job. Among
Control and days hospitalized: medical records those who gained a competitive job,
N = 87. Work choice (job club approach) and clinician report the groups did not differ in mean days
Intervention group, n = 43 (M age = • Self-reported involvement with crimi- worked.
42.9, 77% male). nal justice system
• Self-reported recovery: Recovery The groups had similar rates of adverse
Control group, n = 44 (M age = 44.6, outcomes. 24% of intervention and 19%
Assessment Scale
82% male). of control participants were arrested, and
51% of intervention and 40% of control
Inclusion criteria: Unemployed clients
participants were hospitalized. Self-
with SMI and justice system involvement;
reported recovery did not differ between
enrolled in mental health treatment; served
groups.
by a designated IPS team; no competitive
employment in past 3 mo; no prior IPS job
search or support services; diagnosis of SMI
according to state criteria (i.e., schizophre-
nia spectrum disorder, bipolar disorder, or
other psychotic disorder and either signifi-
cant treatment history or significant func-
tional impairments); aged ≥18, expressed
interest in a competitive job; self-disclosed
criminal justice history; no legal, physical, or
other restriction, including pending criminal
charges, that would prevent participating
over 12-mo follow-up; attendance at 2
informational groups; capacity and willing-
ness to give informed consent
Burns et al. (2009) Level I Intervention Competitive employment for ≥1 day No significant differences were found
IPS between groups at final follow-up in
RCT terms of clinical and social functioning
Control outcomes.
N = 312. TVR
Intervention group, n = 156. Participants who worked during the
18-mo study period had significantly bet-
Control group, n = 156. ter global functioning in terms of symp-
toms and disability, fewer negative and
Inclusion criteria: Psychotic illness, aged
general symptoms, and less social dis-
18 to local retirement age, had been ill,
ability than those who had not worked.
had major role dysfunction for ≥2 yr, were
Participants who had worked were also
living in the community, had not been in

more likely to be in remission for the last
competitive employment in preceding year,
6 mo of the study.
wanted to enter competitive employment
A34
(Continued)

Campbell et al. (2010) Level I Intervention • Job acquisition In all studies, IPS produced superior com-
Newly established IPS programs • Job retention petitive employment outcomes, including
Regression analysis of 4 RCTs job acquisition, time to 1st job, tenure,
Control total hours worked, and earnings.
N = 681 participants. Established VOC services; all comparison
Intervention groups, n = 307. services were highly regarded active A significant covariate, work history, did
programs, considered at the time to be not appear to be a robust predictor for
Comparison groups, n = 374. state of the art employment outcomes in high-fidelity
supported employment. Receiving SSI—
Inclusion criteria: Lack of and desire for
with or without SSDI—was associated
competitive employment, attendance at
with poorer job retention.
research information groups, able and
willing to give informed consent, no
significant medical condition that would
preclude working or participating in
assessment interviews
Campbell et al. (2011) Level I Intervention • Obtaining a job Large effect sizes were found for IPS
IPS • Total weeks worked across all outcomes: job acquisition,
Systematic review and meta-analysis • Job tenure total weeks worked, and job tenure. In
Control every demographic and clinical subgroup
N = 4 studies. TVR approaches using stepwise models examined, IPS participants had better
N = 681 participants. and brokered services competitive employment outcomes than
control participants.
Intervention groups, n = 307.
A few exceptions did emerge; partici-
Control groups, n = 374.
pants with more than a high school edu-
Inclusion criteria: Participants in cation benefited less than those with less
Manchester and Concord, NH, education, and those who were divorced
Washington, DC, Hartford, CT, and or separated fared relatively poorly.
Chicago, IL, who met criteria for SMI
Axis I or II plus severe and persistent
impairment in psychosocial functioning;
unemployed at time of study admission;
desired competitive work; able and
willing to give informed consent; no
significant medical conditions that would
preclude participation; required to attend
multiple research information meetings
(Continued)
A35

Catty et al. (2008) Level I Intervention Primary IPS services were more effective than VOC
IPS • Competitive employment services for every vocational outcome.
RCT (6 sites) 54.5% of IPS participants worked ≥1 day,
Control Secondary compared with 27.6% of VOC partici-
N = 312. Usual VOC using train-and-place model • No. of hours worked pants, and IPS participants worked nearly
Inclusion criteria: Psychotic illness, aged • No. of days employed (regardless of 4× as many hours (428.8 vs. 119.1) over
18 to local retirement age, major role hours worked per week) the 18-mo follow-up period. Of those who
dysfunction for ≥2 yr, resided in the worked, duration of the longest held job
community, had not been in competitive was 2× as long for IPS participants (214
employment in preceding year, wanted days) as for VOC participants (108 days).
to enter competitive employment
Chan et al. (2015) Level I Intervention Primary CACR enhanced productivity outcomes,
CACR Employment rate including employment rate, total days of
Meta-analysis work in a year, and total annual earn-
Control Secondary ings. CACR incorporated into work ther-
N = 9 studies (8 RCTs and 1 prospective Usual VOC services • Total days of work in a year
controlled study) apy programs enhanced employment rate
• Total annual earnings and total annual earnings, and CACR
N = 749 (M age = 36.4, 64% male in 8 incorporated into supported employment
of 9 trials; outpatient settings n = 526, programs significantly improved only
inpatient settings n = 223). total annual earnings.
Inclusion criteria: Studies published 24 hr of computer-based cognitive
2005–2014; participants from United exercise training was able to produce
States, Germany, Italy, Singapore, and significant improvements in total days
Japan aged ≥18 diagnosed with schizo- of work and total annual earnings. An
phrenia, schizoaffective disorder, or unexpected result was that longer train-
bipolar affective disorder according to ing time did not further enhance produc-
an established criterion-based diagnostic tivity outcomes.
system; prospective study with CACR as
intervention; ≥1 productivity outcome
reported, including employment rate,
total days of work in a year, or total
annual earnings
(Continued)
A36

Chuang et al. (2015) Level IV Intervention Positive employment outcomes and 4 variables—education, hand function,
Prevocational training program with predictors core strength, and vocational counsel-
Retrospective cohort study follow-up interviews posttraining ing service use—reached significance
N = 58 (M age = 34.4, 60.3% male). for discerning employment outcomes.
Participants with an associate or other col-
Inclusion criteria: Participants discharged lege degree; who had hand function at the
from regional psychiatric hospital in level of good, fair, or mild impairment; who
central Taiwan who completed entire had core strength at the level of excellent,
course of in-house prevocational train- good, or average; and who had received
ing program and follow-up employment vocational counseling services were more
outcome interviews likely to be employed (sheltered, sup-
ported, or competitive employment).
Cook et al. (2008) Level I Intervention • Competitive employment, defined A significant interaction effect between
Experimental supported employment as a job that pays minimum wage or diagnosis and study condition revealed
RCT (7 sites) program using models following criteria higher; is located in a mainstream, that those with schizophrenia receiving
N = 1,273 (M age and gender not established at the study’s outset for socially integrated setting; is not set supported employment had outcomes
reported). best-practice supported employment: aside for people with disabilities; and significantly better than all other partici-
integrated services delivered by a is held independently (i.e., not agency pants combined. The findings indicate
Inclusion criteria: Met diagnosis, dura- multidisciplinary team, placement into owned) that supported employment helps
tion, and disability requirements for competitive employment, development ameliorate some of the barriers faced
severe and persistent mental illness as of jobs tailored to clients’ career prefer- by people with schizophrenia and point
defined by Center for Mental Health ences, job search process that began to the importance of offering supported
Services; aged ≥18; willing to work; pro- immediately on program entry, and pro- employment services to this population.
vided written informed consent vision of ongoing vocational supports
Control
Services as usual
Cook et al. (2016) Level I Intervention • Labor force participation Significant vocational advantage accrued
Evidence-based supported employment • Earnings to recipients of evidence-based sup-
Long-term results of large RCT • Attainment of Social Security ported employment in the decade after
Control Administration nonbeneficiary status service delivery in terms of earnings from
N = 449. Usual services alone or usual services through suspension or termination of employment, amount of earnings, and
Intervention group, n = 234 (M age = plus enhanced VOC disability cash payments due to work achievement of nonpayment status fol-
38.1, 53.8% male). lowing suspension or termination of SSI
or SSDI cash benefits because of work.
50.2% male).
Inclusion criteria: Aged ≥18, DSM–IV

Axis I diagnosis of mental illness, desired
employment, was unemployed (except at
1 site), provided informed consent
A37
(Continued)

Davis et al. (2015) Level I Intervention • Quantity of work (total hours and MIRRORS participants sustained work
MIRRORS (Mindfulness Intervention weeks worked) longer and performed better at a time-
RCT for Rehabilitation and Recovery in • Quality of work: WBI limited work placement than those
N = 34. Schizophrenia), based on mindfulness- who received a supportive intervention.
based stress reduction modified for Although attrition occurred in both con-
Intervention group, n = 18 (M age = schizophrenia, offered as an adjunct to ditions across the 16-wk program, 78%
53.2, 94% male). standard VOC services of intervention participants remained
in the program for the entire 16 wk vs.
Control group, n = 16 (M age = 50.1, Control 56% of control participants.
100% male). Intensive support consisting of a weekly
group session with discussion of work-
related issues that facilitated participants
phrenia or schizoaffective disorder, in
helping each other problem solve
stable phase of illness (i.e., no hospi-
talizations or changes in psychotropic
medication or housing in previous
month)
Eack et al. (2011) Level I Intervention • No. of individuals competitively A greater proportion of intervention
Cognitive enhancement therapy employed participants were competitively employed
RCT • Weekly earnings, whether work was in paid jobs after 2 yr of treatment
Control full or part time compared with control participants.
N = 58 (M age and gender not Enriched supportive therapy
reported). • Type of occupation engaged in Furthermore, the intervention group
• Satisfaction with employment status earned significantly more per week and
Intervention group, n = 31. were more satisfied with their employ-
ment status at the end of treatment. No
significant differences emerged between
Inclusion criteria: Diagnosis of schizo- groups with regard to full-time employ-
phrenia, schizoaffective, or schizo- ment, but intervention participants were
phreniform disorder; stabilized on more likely to work on a part-time basis.
antipsychotic medications; experienced
1st psychotic symptom within past 8
yr; IQ >80; no significant substance
abuse within 2 mo before study enroll-
ment; significant social and cognitive
disability
(Continued)
A38

Gibson et al. (2011) Level I Intervention • Social participation (including social The review provides moderate to strong
Interventions related to community skills training) evidence for the effectiveness of social
Systematic review integration and normative life roles • Effectiveness of IADL training skills training and supported employ-
N = 52 studies. according to the following themes: social (including life skills training and ment using IPS in promoting competitive
participation (including social skills train- physical activity), work and education, employment. The evidence for the effec-
Inclusion criteria: Level I–III studies ing), IADLs (including life skills training neurocognitive training, intensity and tiveness of life skills and IADL training
published in an English-language peer- and physical activity), work and educa- duration of intervention, client- and supported education in improving
reviewed journal; participants with diag- tion, neurocognitive training, intensity centered intervention, and context and performance is moderate, as is the evi-
nosis of SMI aged 18–65; interventions and duration of intervention, client- environment of intervention dence for neurocognitive training paired
within scope of occupational therapy centered intervention, and context and with skills training in the areas of work,
practice environment of intervention social participation, and IADLs. The
evidence is limited but positive for client-
centered intervention and increased
intensity and duration of treatment. The
evidence is inconclusive that providing
intervention in a natural context is more
beneficial than in a clinic setting.
Gutman et al. (2009) Level I Intervention • Participant Comfort with the Student The results suggest that the Bridge
Bridge Program Role Scale: Task Skills, Interpersonal Program helped participants increase
RCT
Skills, and School Behavior scales their skill level in basic academic areas,
Control • Participant Overall Satisfaction Scale improve professional behaviors and
N = 38 (M age and gender not reported).
TAU at their own mental health facility • No. of participants who engaged social skills needed for school and work
Intervention group, n = 21. in some type of further educational settings, and gain the confidence to
Control group, n = 17. pursuit or obtained employment on test their skills in the larger community.
study completion Factors that correlated most with success
Inclusion criteria: Aged ≥18, own legal in the program included adherence to a
guardian, able to cognitively weigh study medication routine, possession of a sta-
risks and benefits to decide whether to ble residence, and motivation to attend
participate, diagnosis of psychiatric disor- the program regularly. Prior education
der by a physician, receiving medication level, no. of hospitalizations in the past
management from a licensed psychiatrist 5 yr, age at illness onset, and parental
or nurse practitioner, interested in pursu- education level had no relationship to
ing further education, willing to commit success in the program.
to attend all 12 sessions of the program,
able to function adequately in most daily
living activities, ready to begin greater
community participation, minimum 10th-
grade reading and writing level
(Continued)
A39

Hees et al. (2013) Level I Intervention Primary During the 18-mo study period, 91% of
TAU + adjuvant OT (with increased focus • Work participation: absenteeism, time participants achieved at least partial RTW
RCT
on 3 elements: early return to the work until partial or full RTW (92% of the intervention group; 89% of
N = 117. situation according to the place-then- the control group), and 63% of partici-
train principle, increased focus on work- Secondary pants achieved full RTW (66% interven-
Intervention group, n = 78 (M age = related coping and self-efficacy, and • Severity of depression tion; 56% control).
43.8, 53% male). enhanced communication among the • At-work functioning
various stakeholders involved • Health-related functioning In this highly impaired population,
• Coping with work-related situations no significant benefit was found for
41% male).
Control adjuvant OT with regard to overall
Inclusion criteria: Aged 18–65; diagnosis TAU only work participation. However, adjuvant
of major depressive disorder according to OT increased the probability of long-
DSM–IV criteria; absent from work ≥25% term RTW with remitted depression
of contract hours because of depression; and better work and role functioning.
duration of depressive disorder ≥3 mo or Adjuvant OT also increased long-term
duration of sickness absence ≥8 wk; rela- depression recovery in terms of both
tionship between depressive disorder and symptom reduction and sustained
work situation (i.e., work was a determi- remission.
nant of depressive disorder and contributed
Employees in adjuvant OT used less
substantially [>25%], or depressive symp-
high-cost medical treatment than
toms reduced productivity or hindered RTW)
those in TAU only (i.e., fewer ses-
sions with a psychiatrist and fewer
days of day treatment or inpatient
treatment).
Heslin et al. (2011) Level I Intervention Vocational Significantly more IPS participants (22%)
Supported employment with IPS model • Competitive employment rate had gained competitive employment
RCT that linked 4 employment specialists • Duration before 1st job after 2 yr than control participants
N = 219. with community mental health teams, • Hours worked (11%).
focused on rapid placement with con- • Total duration of jobs
tinued follow-up support, and sought to • Salary per hour
find employment opportunities that were
consistent with participants’ preferences,
skills, and abilities
(Continued)
A40

Intervention group, n = 109 (M age = Control Nonvocational Whether the participant had a job in the
38.4, 69% male). TAU (existing psychosocial rehabilitation Cost-effectiveness: 5 yr before baseline predicted employ-
and day care programs available in local • Service use data (Client Service ment outcome.
Control group, n = 110 (M age = 38.3, area) Receipt Inventory) combined with unit
66% male). cost information The intervention group had significantly
• Cost data combined with main shorter duration before 1st job than the
Inclusion criteria: Adults with SMI in control group.
England receiving outpatient or com- outcome (% of participants in employ-
munity psychiatric care from local mental ment during 2-yr follow-up period) Of the participants employed, the inter-
health services, SMI (duration >2 yr, Clinical measures: vention group showed a trend toward
GAF score ≤60, diagnosis of psychotic or • Camberwell Assessment of Needs more hours worked compared with the
chronic affective disorder), unemployed • BPRS control group, but there was no differ-
≥3 mo, aged 18–65, able to read and • RSES ence between groups in total duration
speak sufficient English to give written • Overall MANSA of job.
informed consent • GAF The control group had significantly
higher salary per hour than the interven-
tion group.
No significant differences between

groups were found in overall costs,
service costs, or medication costs over
2 yr. A cost difference of £2,361 was
found in favor of the IPS group (not sig-
nificant). Based on the point estimates
of costs and outcomes, IPS was seen as
dominant.
No significant differences in clinical out-

comes were found.
Hodge et al. (2010) Level I Intervention • Cognition The NEAR technique was associated with
NEAR, immediate treatment for 15 wk • Psychosocial function broad cognitive improvement after 15 wk
RCT (9 sites)
of cognitive remediation. Cognitive
N = 40 (M age = 31.3, 60% male).
(Continued)
A41

Intervention group, n = 22. Control improvement was accompanied by a

Wait list for 15 wk, then NEAR significant improvement in psychosocial
functioning.
phrenia by trained psychiatrist; stable
on medication for ≥2 mo; stable resi-
dence; premorbid IQ >70 determined by
WRAT–R; PANSS conceptual disorganiza-
tion score <5; impairment in 1 cognitive
domain >1 SD; no evidence of significant
head injury, neurological disease, learn-
ing disorder, or electroconvulsive therapy
in past 6 mo or current diagnosis of sub-
stance dependence (other than nicotine);
English speaking
Hoffmann et al. (2012) Level I Intervention Vocational After the 1st year, the rate of competitive
Supported employment (derived from but • Rates of competitive employment employment reached a mean of 48.2%
RCT not fully implemented IPS model) • Time to 1st job (i.e., time from study in the supported employment group and
N = 100. entry to 1st job start) 18.5% in the TVR group. 58.7% of the
Control • Total weeks competitively employed intervention group were ever competi-
Intervention group, n = 46 (M age = TVR (train-then-place model) • Hours worked per week during 2nd year tively employed, compared with 25.9%
33.5, 65% male). • Percentage of participants employed of the control group. In the 2nd year,
≥20 hr/wk intervention participants were competi-
• Job tenure in longest competitive job tively employed for 24.5 wk, compared
65% male).
held during follow-up period with 10.2 wk in the control group. The
Inclusion criteria: Participants with SMI in • Employment status at 24-mo follow-up groups showed no significant differences
Switzerland who received authorization • Total earnings in 2nd year in the nonvocational outcome criteria.
for VOC from Swiss Invalidity Insurance, • Employment status at 24-mo follow-up
aged 18–64, stabilized mental disorder • Hours worked per week at 24-mo
in accordance with ICD–10 criteria, inter- follow-up
ested in competitive employment, out • Hourly wage at 24-mo follow-up
of competitive work at time of signing • Monthly income at 24-mo follow-up
consent form
Nonvocational
• Psychiatric symptoms
• Global functioning
• Relapses (no. of hospitalizations, time
spent in hospital)
• Coping with stress

• Self-perceived and objective QOL
A42
(Continued)

Hoffmann et al. (2014) Level I Intervention • Competitive employment, defined as The beneficial effects of supported
Supported employment (derived from but holding a job paying at least minimum employment on work at 2 yr were sus-
Long-term follow-up of RCT not fully implemented IPS model), with wage (about US$10) for ≥2 wk on tained over the 5-yr follow-up period.
N = 100. interviews at baseline and 1, 2, and 5 yr open labor market (i.e., excluding jobs Participants in supported employment
protected for people with disability, were more likely to obtain competitive
Intervention group, n = 46 (M age = Control such as transitional employment) work than those in TVR (65% compared
33.5, 65% male). TVR (train-then-place model) • Rates of competitive employment with 33%), worked more hours and
• Length of employment ≥50% (130 weeks, earned more wages, and had
wk) in a competitive job longer job tenures. Intervention par-
65% male).
• Total and annualized weeks competi- ticipants reduced their reliance on sup-
Inclusion criteria: Aged 18–64, stabilized tively employed ported employment services for retaining
mental disorder in accordance with ICD– • Job tenure in longest competitive job competitive work during the 2- to 5-yr
10 criteria, mandated by Swiss Invalidity held follow-up phase and were significantly
Insurance State Office, interested in com- • Mean hours worked per year in com- less likely to be hospitalized, had fewer
petitive employment, out of competitive petitive job psychiatric hospital admissions, and
work at time of signing consent form • Average yearly income spent fewer days in the hospital.
• Average hourly wage in competitive
employment The social return on investment was higher
• Cumulative duration of competitive for supported employment participants,
employment whether calculated as the ratio of work
earnings to vocational program costs or of
work earnings to total vocational program
and mental health treatment costs.
Howard et al. (2010) Level I Intervention • Competitive employment over previ- No evidence was found of significant
IPS ous 12 mo benefit of the IPS model in helping
RCT • Service use over previous 12 mo participants with SMI obtain competi-
Control • Employment status over previous 12 tive employment. The study context—a
N = 219. TAU (TVS) mo socioeconomically deprived area with a
Intervention group, n = 109. somewhat rigid welfare benefits system,
Psychosocial functioning: and an intervention provided by an exter-
Control group, n = 110. • MANSA Version 2 nal agency—may have made successful
• Camberwell Assessment of Need implementation of the IPS model more
Inclusion criteria: People with SMI
• RSES challenging.
recruited from community mental health
• BPRS
teams in South London, England; received
• GAF
outpatient or community psychiatric care
• Client Service Receipt Inventory
from local mental health services; had SMI
>2 yr; GAF score ≤60; diagnosis of psy-
chotic or chronic affective disorder; aged
18–65; able to read and speak sufficient
English to give written informed consent;
unemployed ≥3 mo; desired competitive
employment
A43
(Continued)

Kidd et al. (2014) Level I Intervention Primary Although both groups demonstrated
CR + supported education • Academic functioning improvements in cognitive functioning,
RCT no evidence was found that CR facili-
Control Secondary tated improvement in cognition beyond
N = 37. Supported education only • Cognitive measures gains associated with supported educa-
Intervention group, n = 19 (M age = • Mental health tion. This observation was sustained at
33.7, 42% male). 4-mo follow-up. However, improvements
in academic functioning were associ-
ated with CR. The intervention group
50% male).
showed a greater rate of completion of
Inclusion criteria: Aged ≥19 yr; newly the 1st semester. At follow-up, a trend
enrolled in supported employment was found toward enhanced teacher-
program; diagnosis of schizophrenia or rated attitude, preparedness, focus on
other psychotic condition as identified task, effort, and professionalism, and a
by a physician in student referral form; significant enhancement in contributions
no history of mental retardation, brain was found.
injury, or other neurological condition;
stable use of medications ≥3 mo and no
plans to change medications; proficiency
in English
Kinoshita et al. (2013) Level I Intervention Primary Findings indicate that supported employ-
Supported employment • Employment—days in competitive ment increased length and time of
Systematic review employment over 1-yr follow-up employment and that people in sup-
Control ported employment found jobs more
N = 14 RCTs. Other vocational approaches Secondary quickly.
N = 2,265. • Employment or education—earnings,
tenure
Inclusion criteria: Adults with SMI using • Attrition
community psychiatric or mental health • Global state
services; working age (16–70); unem- • Mental state
ployed; SMI, defined as schizophrenia or • Service use
schizophrenia-like disorder, bipolar disor- • QOL
der, or depression with psychotic features • Social and general functioning
• Adverse effects
• Economic costs
(Continued)
A44

Kin Wong et al. (2008) Level I Intervention Vocational The intervention group showed signifi-
Supported employment including IPS, • Competitive employment rates cant improvements compared with the
RCT employment specialist integrated into • No. of jobs control group in obtaining competitive
N = 92. clinical management team, and specialist • Time to 1st job employment, no. of competitive jobs,
who assisted with securing employment • Total days employed total income earned, days worked, and
Intervention group, n = 46 (M age = and on-the-job training • Total earnings sustained competitive job tenure. 70%
32.4, 54% male). • Job wages per day of the intervention group and 29% of
Control • Job tenure the control group were competitively
Control group, n = 46 (M age = 34.7, CVR (prevocational training in work employed during the 18-mo study period.
65% male). groups in a simulated environment) Nonvocational
• Psychiatric symptoms No significant differences were found in
Inclusion criteria: Adults with SMI from OT
• BPRS nonvocational results.
department of psychiatric hospital in Hong
• Self-perceived QOL
Kong, diagnosed ≥2 yr with mental illness,
• Hong Kong Chinese WHOQOL
aged 18–55, interested in competitive
employment, no serious medical condition
that might affect long-term employment
Kukla & Bond (2013) Level I Intervention • Symptoms Participants who obtained a job worked
IPS • Psychiatric hospitalizations an average of over 20 hr/wk and a
Longitudinal analysis of data from RCT • QOL total of over 40 wk during the study
Control • Social networks period. Significantly better employment
N = 187 (M age = 38.8, 63.6% male). DPA, a stepwise vocational model • PANSS outcomes were found for the IPS group
Intervention group, n = 92. • QOLI compared with the DPA group.
Control group, n = 95. Overall, the groups had comparable non-
vocational outcomes across 24 mo. They
Inclusion criteria: Clients with SMI
did not differ significantly on symptoms
enrolled in psychiatric rehabilitation ser-
or symptom domains at baseline or dur-
vices who expressed an interest in work-
ing follow-up; both groups reported mild
ing and had been unemployed for ≥90
to moderate symptom levels across the
days before study entry, attendance at 2
study period. Similarly, the groups did
informational sessions about the study,
not differ on days of psychiatric hospi-
no physical illness that would prevent
talization, overall QOL, or QOL domains
2-yr study participation, agreement to be
at baseline or any follow-up period. IPS
excluded from services provided in non-
participants reported significantly better
assigned vocational program
social networks than DPA participants at
baseline and at 3 mo. The groups did not
differ on social networks at subsequent
follow-up periods.
(Continued)
A45

Kukla et al. (2014) Level I Intervention • Employment outcomes and factors Engagers worked an average of 22.6 of
IVIP + CBT for “engagers” that predict treatment engagement the possible 26 wk. Average total hours
Longitudinal follow-up of RCT vs. nonengagement and full vs. partial worked across 26 wk was 473.4, and
Control response in CBT targeting work mean hours worked per week was 15.5.
N = 50. IVIP + CBT for “nonengagers” • PANSS Nonengagers had significantly worse
Intervention group, n = 40 (M age = • RSES employment outcomes across the study;
45.8, 85% male). • WAIS–III they worked a mean of 3.1 of the pos-
• WCST sible 26 wk, 42.1 total hours across the
study period, and 1.9 hr/wk.
80% male).
2 aspects of intellectual functioning—
Inclusion criteria: Participants with a
working memory and visuospatial process-
schizophrenia spectrum disorder receiv-
ing speed—were important predictors
ing medication management services
of whether participants engaged in the
from an outpatient Veterans Affairs
intervention. Greater severity of symptoms
psychiatry clinic, in stable phase of illness
was also associated with lack of engage-
(i.e., no hospitalizations or changes in
ment. Baseline variables, including symp-
psychotropic medication or housing in
toms, largely did not predict work success,
month before entering study), expressed
except for age; older participants were
interest in working
more likely to stay longer in employment.
Lee (2013) Level I Intervention • Clinical, neuropsychological, and Compared with the control group, the
Computerized cognitive rehabilita- functional outcomes intervention group exhibited significant
RCT tion (Cog-trainer) group plus usual improvements in attention, concentra-
N = 60. rehabilitation tion, and working memory. The interven-
tion group also showed improvement in
Intervention group, n = 30 (M age = Control the Work Quality subscale of the WBI.
43.5, 53% male). Usual rehabilitation only Intervention participants demonstrated
significantly greater improvements in
cognitive and functional outcome mea-
56% male).
sures, specifically CPT, digit span, and
Inclusion criteria: Met DSM–IV criteria work behavior, compared with control
for schizophrenia; treated with stable participants. No significant benefits
dose of same antipsychotic therapy for of the intervention were found for
≥6 mo and was responsive and clinically symptoms.
stabilized; participated in a rehabilitation
program, including psychosocial pro-
grams; showed no evidence of substance
dependence or abuse, comorbid diagno-

sis on Axis I or II, epilepsy, or other major
neurological illness or mental retardation
A46
(Continued)

Lysaker et al. (2009) Level I All participants were offered and Vocational The intervention group worked signifi-
accepted a 26-wk job placement in an • Hours worked per week cantly more hours and weeks than the
RCT entry-level medical center position super- control group over 6 mo. Both groups
vised by the regular job site supervisors Nonvocational worked significantly fewer hours over
N = 100. • WBI
and were paid $3.50/hr for ≤20 hr/wk of time.
Intervention group, n = 50 (M age = work activity. • Measure developed specifically to
45.9, 84% male). assess behavior at work for people The intervention group had significantly
Intervention with severe and persistent mental greater WBI scores (averaged over 6
Control group, n = 50 (M age = 47.1, IVIP + CBT in group and individual inter- illness mo) than the control group. Both groups
86% male). ventions targeted at dysfunctional beliefs • Direct observation of work behavior showed overall improvements in work
about self (e.g., “I cannot succeed”) and and interview with supervisor performance over time; the intervention
work experiences (e.g., “my supervisor group had overall better work perfor-
phrenia or schizoaffective disorder,
criticizes my work and dislikes me”) mance than the control group but did not
receiving medication management by an
improve at a different rate.
assigned clinician, in postacute phase of Control
illness (no hospitalizations or changes in Support services consisting of weekly
psychotropic medication or housing in group and individual sessions offering
previous month) support and discussion of work-related
issues and concerns with no specific
curriculum
McGurk et al. (2009) Level I Intervention Vocational No significant difference was found in
CR + hybrid VOC, including a 3-mo CR • Competitive work or internship competitive employment during 2 yr;
RCT program, VOC services (see control), 24 • Weeks and hours worked 39% of the intervention group and 31%
N = 34. hr of computer-based cognitive exercises • Wages earned of the control group were employed.
(COGPACK Version 6.0), and a weekly
Intervention group, n = 18 (M age = group (topics included the role of cogni-
45.5, 61% male). tion in job performance and problem
solving about compensatory strategies
for dealing with common challenges on
56% male).
the job)
Control
Hybrid VOC, including combined voca-
tional and day treatment program; paid
internships and supported employment;
services including case management,
(Continued)
A47

Inclusion criteria: Age ≥18, SMI as pharmacological treatment, housing Nonvocational The intervention group showed signifi-
defined by New York Office of Mental support, and work preparatory activities; • Premorbid academic achievement: cantly greater no. of weeks worked, no.
Health, interested in obtaining work, supported employment for participants WRAT, Reading subtest of hours worked, and wages earned in
history of unsatisfactory job ending (i.e., who had satisfactory performance in • Short-term memory: Digit Span, internships compared with the control
was fired from or quit a job before secur- internship WAIS–R group.
ing another job) • Psychomotor speed: Trails A
• Information processing speed: Digit For competitive employment and internships
Symbol Substitution Test, WAIS–R combined, the intervention group worked
• Verbal learning and memory: CVLT significantly more weeks (but not hours)
• EF: Trails B than the control group and showed a non-
• EF: WCST significant trend toward greater wages.
• Composite measure of overall cogni- The relationship between composite cog-
tive functioning (not including the nition scores at baseline and employment
WRAT) outcomes for the intervention group was
not significant. The control group showed
a significant correlation between higher
composite cognition scores at baseline
and greater total hours and wages (mar-
ginally significant for total weeks).
The intervention group improved signifi-

cantly compared with the control group
on the Trails B (EF) and the CVLT (Trials
1–5 and Long-Delay Free Recall). The
control group improved significantly com-
pared with the intervention group on the
Digit Span (Forward). No significant dif-
ference was found in cognitive composite
scores (even after removing Digit Span
[Forward]).
Participants with no current alcohol- or

drug-use disorder worked significantly
more total hours compared with par-
ticipants with current substance abuse
disorders in both treatment groups.
No significant group difference in comor-

bid medical conditions was found.
(Continued)
A48

McGurk et al. (2010) Level III Intervention Vocational Participants worked significantly more
Cognitive remediation, including TSW in Competitive employment: hours per month in competitive employ-
Single group pre–post addition to supported employment (IPS • Hours, weeks, wages, and no. of ment over the 2 yr after joining the TSW
N = 23 (M age = 38.8, 47.8% male). model) at a Psychosocial Clubhouse; 24 hr competitive jobs program than before. 60% achieved
of computer-based cognitive exercises competitive employment, 14% obtained
Inclusion criteria: SMI according to State (COGPACK Version 6.0); collaborative job Other work-related: volunteer jobs, and 14% enrolled in
of New York criteria, member of the search planning and support with a cogni- • Volunteer work or enrollment and school over the 2-yr follow-up period.
Psychosocial Clubhouse and enrolled tive specialist and employment specialists; completion of classes toward a degree
in the supported employment program and VOC programs at the Clubhouse, or certificate Significant improvements were found
there, was not employed and desired including transitional employment, • Hours and weeks worked or weeks for overall cognitive composite score,
competitive work, history of difficulties enclave work, and community-based enrolled CVLT Long Delay, Free Recall, and Total
with job attainment or retention, inter- supported employment, as well as a Learning (verbal learning and memory);
Nonvocational Trails A (speed of processing); and Trails
ested in participating in TSW, willing to “Back to Work” seminar series on entitle- Cognitive functioning:
sign informed consent to participate in ments planning and management, help B (EF). No significant changes were
• Processing speed: Trails A observed for WAIS–III Letter–Number
research assessments obtaining accommodations based on the • Verbal learning and memory:
Americans With Disabilities Act, and links Sequencing (working memory) or WCST
CVLT (novel problem solving).
to other services • Verbal working memory: Letter–
Number Sequencing, WAIS–III
• EF: Trails B
• EF for novel problem solving: WCST
• Composite measure of overall
cognitive functioning
McGurk et al. (2015) Level I Intervention Vocational Regarding competitive employment,

TSW + ESE consisting of a cognitive spe- Competitive employment: the intervention group had significantly
RCT cialist who was a member of the employ- • No. of jobs better results than the control group for
N = 107. ment team and participated in team • Weeks and hours worked no. of jobs, weeks and hours worked,
meetings, assessment of clients’ cognitive • Wages earned wages earned, and no. who found com-
Intervention group, n = 57 (M age = strengths and weaknesses, cognitive • Duration of 1st job petitive work. 60% of the intervention
45.1, 59.6% male). exercise practice (COGPACK Version • No. who found any competitive group and 36% of the control group
7.0), and coaching and teaching on cop- work found competitive employment during
ing and compensatory strategies the study period.
(Continued)
A49

Control group, n = 50 (M age = 42.9, Control Any paid work: Regarding any paid work, the interven-
72% male). ESE with IPS model enhanced by teach- • No. of jobs tion group had significantly better results
ing employment specialists about cogni- • Weeks and hours worked than the control group for weeks and
Inclusion criteria: Met New Hampshire tive impairments that interfere with work • Wages earned hours worked, wages earned, duration
or Illinois state definitions of SMI, with a functioning and strategies to help clients • Duration of 1st job of 1st job, and no. of participants who
DSM–IV Axis I diagnosis and persistent cope with them • No. who found any paid work found any paid work.
impairment in multiple areas of func- • Employed 1+ days
tioning; failed to respond to supported Regarding cognitive results, the inter-
employment (i.e., had been enrolled in a Nonvocational vention group had significantly greater
supported employment program for ≥3 Cognitive functioning: improvement in scores compared with
mo but did not work within that period, • Composite cognitive score the control group for composite cognitive
or quit or was fired from a competitive • Trails A score, Trails B, and BVMT–R Total Trials.
job that lasted <3 mo); wanted to work • Trails B
(i.e., responded yes to “Do you want a • Symbol coding: Brief Assessment of Regarding Group × Diagnosis interac-
competitive job?”); showed no evidence Cognition in Schizophrenia tions, participants with schizophrenia or
of traumatic brain injury or other medical • HVLT–R, Delayed schizoaffective disorder in the interven-
condition with a profound effect on brain • HVLT–R, Sum 1–3 tion group improved more than those in
functioning • Spatial span the control group, compared with other
• Letter–number span diagnoses, for the Category Fluency Test
• Maze test, NAB and the CPT–IP.
• BVMT–R, Delayed Recall Regarding symptoms and QOL, the
• BVMT–R, Total Trials 1–3 groups did not differ significantly in
• Category Fluency Test changes in symptoms or QOL measures.
• Mayer–Salovey–Caruso Emotional
Intelligence Test
• CPT–IP
Symptoms and QOL:

• Expanded BPRS
• QLS
Michon et al. (2014) Level I Intervention Vocational 2 of the 4 participating agencies scored
Supported employment with IPS model, • Proportion of participants who were good to high on IPS model fidelity
RCT employment specialists added to mul- competitively employed (worked 1+ in every assessment, and 2 scored
N = 151. tidisciplinary community mental health days) during study follow-up moderate.
teams • Total no. of days worked in competi-
tive employment
• Average no. of days and hours worked
per week while employed
(Continued)
A50

Author/Year Participants/Inclusion Criteria Intervention and Control Outcome Measures Results (Continued)
Intervention group, n = 71 (M age = Control Nonvocational At 30 mo, significantly more intervention
34.1, 73% male). TVR • QOL: MANSA participants (44%) than control par-
• Self-esteem: RSES ticipants (25%) had found competitive
Control group, n = 80 (M age = 35.6, • Mental Health Inventory–5 work. Results remained significant after
75% male). controlling for site, fidelity, and mental
Inclusion criteria: Aged 18–65, explicit health at baseline. Significance was
wish for competitive employment, willing reached between 6 and 18 mo.
to give informed consent, recruited at 4 The intervention group worked signifi-
sites from regional community mental cantly more total hours than the control
health care divisions specifically targeted group. For those who were employed,
at adults with SMI in the Netherlands no significant difference between groups
was found in total or weekly hours
worked.
No significant differences were found

between groups for all 3 nonvocational
measures. Significant effects were found
for being competitively employed on
all 3 nonvocational outcomes for both
groups.
Modini et al. (2016) Level I Intervention Vocational Study interventions showed moderate
Supported employment with IPS model • Competitive employment rates, scored to high fidelity with the IPS model.
Systematic review and meta-analysis as a binary outcome (i.e., either Quality of studies was evaluated as
Control achieved competitive employment or excellent = 0, good = 17, fair = 2, or
N = 19 studies. TAU, TVR, TVS, or CVR failed to do so), which allowed risk poor = 0.
ratios to be calculated
• Annual unemployment rate and GDP
growth for country in which study was
conducted
(Continued)
A51

Inclusion criteria: RCTs comparing IPS Nonvocational Overall pooled risk ratio for com-
with TVS, IPS intervention demonstrated • Quality of studies petitive employment using IPS com-
moderate to high fidelity as measured pared with TVR was 2.40 (95% CI
by the IPS Fidelity Scale or evidence [1.99–2.90]).
provided that fidelity was adhered to,
participants had severe mental disorders Meta-regressions indicated that neither
(i.e., schizophrenia or schizophrenia-like geographic area nor unemployment
disorder, bipolar disorder, or depression rates affected the overall effectiveness
with psychotic features), studies pub- of IPS. IPS was relatively more effective
lished in English for studies in countries with higher GDP
growth. However, even when a coun-
try’s GDP growth was <2%, IPS was
significantly more effective than tradi-
tional VOC, and its benefits remained
evident over 2 yr.
The pooled risk ratio for gaining com-

petitive employment within the 1st
year after IPS was commenced com-
pared with TVR was 2.59. The pooled
risk ratio for gaining competitive
employment within the 2nd year after
IPS was commenced compared with
TVR was 2.41.
Mueser et al. (2014) Level I Intervention • Any competitive work Intervention Group 1 participants
Group 1: Supported employment (IPS), • Any paid work showed significantly better competitive
RCT including rapid job search without exten- • Worked >20 hr/wk work outcomes compared with Group 2
N = 204. sive prevocational assessments or required • Total hours and control participants across all mea-
skills training, focus on competitive jobs in • Total wages sures of competitive employment, includ-
Intervention Group 1, n = 68 (M age = integrated community settings, attention to • Total weeks employed ing any paid work and total weeks of
41.7, 61.8% male). consumer preferences with respect to types • Average weeks per job paid work. Group 1 also showed a trend
of jobs desired and supports provided • Outcomes by ethnic and racial group toward more average weeks of paid
work. Competitive employment rates
(Continued)
A52

Intervention Group 2, n = 67 (M age = Group 2: Psychosocial Clubhouse pro- during 2 yr were as follows: 73.9% for
41.1, 59.7% male). gram, including transitional employment Group 1, 18.2% for Group 2, and 27.5%
approach to VOC and preparatory training for the control group.
Control group, n = 69 (M age = 40.9, activities focused on clerical and janitorial
63.8% male). skills, followed by transitional employment No significant differences among the
and then help in seeking competitive work 3 ethnic or racial groups were found
Inclusion criteria: SMI as determined in regard to employment outcomes.
by State of Connecticut Department of Control Employment outcomes for Latino par-
Mental Health and Addiction Services TAU by vocational service providers ticipants in Group 1 who expressed a
(i.e., DSM–IV–TR Axis I disorder or bor- funded by the state’s vocational services preference for Spanish in the research
derline personality disorder combined agency (e.g., program in which clients interviews were not significantly different
with severe impairment in psychosocial worked in jobs paying subminimum or from those for participants who preferred
functioning), not competitively employed, competitive wages in supervised janito- English.
interested in competitive work, willing rial enclaves in the community)
and able to give informed consent
Poremski et al. (2017) Level I Intervention Vocational The intervention group showed a trend
Supported employment with IPS model, • Employed (worked ≥1 day in a 30-day toward greater participation in competi-
RCT including a focus on quickly obtaining period) tive employment (34%) compared with
N = 90. and maintaining competitive employ- • Nature of job (competitive or shel- the control group (22%) during the 8-mo
ment of clients’ choice and employment tered, regular or casual) good fidelity period (p = .16).
Intervention group, n = 45 (M age = specialists trained and supervised by a • Weekly hours worked
45.2, 64% male). senior member of an experienced local • Wages collected Adjusted odds of obtaining competitive
IPS service and integrated with the clini- employment were 2.4 times greater for
Control group, n = 45 (M age = 47.1, Nonvocational the intervention than for the control
cal team
62% male). • Quality and quantity of help received: group. Other employment outcomes
Control Service Satisfaction Scale (e.g., knowl- were not significantly different between
Inclusion criteria: Recently homeless adults
TAU, including freedom to seek employ- edge of staff, ability to listen and groups.
with mental illness (major depression,
ment by any means of their choice, address concerns, service’s contribu-
mania or hypomania, posttraumatic stress The treatment group scored significantly
some support from case managers, and tion to controlling symptoms)
disorder, panic disorder, mood disorder higher on all service satisfaction ques-
services including training with eventual
with psychotic features, psychotic disorder) tions with the exception of the role of IPS
placement in jobs reserved for people
in Canada, age ≥18, either in absolute
receiving basic social assistance or dis- in dealing with mental health symptoms.
homelessness for ≥7 nights or precariously
ability payments (not integrated with the
housed with ≥2 separate instances of
clinical team)
absolute homelessness in past year
(Continued)
A53

Quee et al. (2014) Level II Intervention Vocational The intervention group showed signifi-
CAT for 8 mo, including psychosocial • Work-related activities (e.g., greenery cantly more hours spent in work-related
2 groups, nonrandomized intervention in the client’s living environ- project, framing center) using data activities than the control group begin-
N = 30. ment; education in compensation strate- from registration system at residential ning at 10 mo and continuing to 16 mo.
gies and use of environmental supports in facility
Intervention group, n = 16 (M age = areas of daily living; intervention strategy The intervention group showed a trend
45.1, 81.3% male). informed by scores on the Frontal Systems Nonvocational toward higher scores on the MCAS at 8
Behavioral Scale, Modified Card Sorting • MCAS mo that did not reach statistical signifi-
Control group, n = 14 (M age = 43.5, • SOFAS cance. No significant differences were
Task, Controlled Oral Word Association
78.6% male). • NSA–M found on the SOFAS or NSA–M.
Test, and Environmental and Functional
Inclusion criteria: Outpatients and inpa- Assessment; and weekly visits by psychi-
tients within the schizophrenia spectrum atric nurse, then TAU (see control)
(DSM–IV) in the Netherlands, aged
Control
18–65, free of alcohol and drug abuse in
TAU, including pharmacotherapy along
6 mo before inclusion
with psychoeducation, CBT, Liberman
modules, psychomotor therapy, creative
arts therapy, educative projects, sports
groups, and peer support groups
Rouleau et al. (2009) Level II Intervention Vocational At 30 wk (discharge), significant differ-

OT–PVP, which combines cognitive, Employment category: ences in category distribution were found
2 groups, nonrandomized cognitive–behavioral, and skill training • No work-related structure between groups.
N = 26. and psychosocial approaches based on • Prevocational rehabilitation program No significant correlations were found
Anthony’s model (Anthony & Liberman, • Adapted work setting between the 18 cognitive measures and
Intervention group, n = 14 (M age = 1986), which offers skills training fol- • Part-time school the work status categories.
35.0, gender not reported). lowed by the integration of clients into • Volunteer work
a chosen environment; varying program • Regular part-time paid work At the end of the study, 71.4% of the
Control group, n = 12 (M age = 31.8, intervention group and 16.7% of the
length (M = 30 wk) • Regular full-time paid work
gender not reported). control group had achieved volunteer or
Control Nonvocational paid work. Rates of competitive employ-
Inclusion criteria: Adults in Canada with
Wait list; TAU (pharmacological treat- • Psychotic symptoms: PANSS ment (full and part time) during 30 wk
schizophrenia or schizoaffective disorder
ment only) • Sustained attention: CPT were 21.4% for the intervention group
(DSM–IV criteria), attended psychiatric
• Visual attention: Trails A and 0% for the control group.
outpatient clinic, expressed desire to
• EF: Trails B
work, no diagnosis of Axis II disorder, Intervention participants showed statisti-
• Verbal attention and short-term
no identified intellectual delays, no sub- cally but not clinically significant reductions
memory: Digit Span section of the
stance abuse disorder, no active neuro- in negative symptoms and general symp-
WAIS–R
logical diagnosis tom scores on the PANSS at discharge.
• EF: WCST
• Long-term memory: RAVLT The control group showed a significant
• Verbal skills: Verbal fluency test increase in scores on delayed recall of the
RAVLT after 3 mo. The intervention group

showed a significant increase in scores
after 3 mo and at discharge on Trails A and
A54
at discharge on total recall on the RAVLT.
(Continued)

Sato et al. (2014) Level II Intervention Vocational No result reached significance, except
CR (12 wk) + supported employment (12 • Competitive employment rate the intervention group used more intern-
2 groups, nonrandomized mo) using Japanese version of COGPACK • Total days employed ship programs for people with a disability
N = 109. exercises for attention, concentration, • Total earnings in the community. Competitive employ-
psychomotor speed, learning, memory, • Rate and days of disability ment during 1 yr was 15.2% for the
Intervention group, n = 52 (M age = and EF as well as additional verbal skills employment intervention group and 14.9% for the
33.1, gender not reported). • Use of internship and VOC programs control group.
Control
Control group, n = 57 (M age = 35.8, Supported employment place-then-train Nonvocational The intervention group scored signifi-
gender not reported). model (12 mo), with addition of employ- • Psychotic symptoms: PANSS cantly higher for negative symptoms
ment specialists to multidisciplinary and • Social functioning: LASMI and general psychopathology on the
Inclusion criteria: Adults in Japan diag-
interagency case management teams • Cognitive functioning: BACS–J PANSS at baseline but showed signifi-
nosed with schizophrenia or schizoaf-
• Cognitive functioning: NAB Maze Test cantly greater improvement in PANSS
fective disorder (F20 or F25 of ICD–10),
• Task performance: digit-checking and total score compared with the control
aged 20–45, outpatient, had been to
napkin-folding tasks in MWS group.
high school or had IQ of ≥70 (WAIS),
had competitive work experience and The intervention group scored sig-
intention to find employment nificantly lower on the Interpersonal
Relations domain of the LASMI at base-
line but showed significantly greater
improvement in the LASMI Interpersonal
Relations and Working Related Behavior
domains compared with the control
group.
The intervention group showed signifi-

cantly greater improvement in verbal
memory, digit sequencing, token
motor, and composite scores of the
BACS–J compared with the control
group.
No significant Group × Time effects were

found for the NAB or the MWS.
Schonebaum & Level II Intervention Vocational WOD before competitive employment

Boyd (2012) Group 1: WOD • Hours worked in competitive had a significant positive impact on total
2 group pre–post employment employment duration. Average duration
Group 2: Clubhouse program certified by • Total employment duration per job increased by 2.3 wk for each 1-hr
N = 177 (M age and gender not the International Center for Clubhouse
reported). • Average duration for each job increase in WOD hours per week prior to
Development • Work cycles employment.
• Work history
A55
(Continued)

Intervention Group 1, n = 89. Nonvocational WOD during competitive employment

• Clubhouse participation: hours attend- had a significant negative relation-
Intervention Group 2, n = 88. ing WOD each week, before employ- ship with total employment duration.
Inclusion criteria: Diagnosis of bipolar ment and after employment Duration per job decreased by 3.8 wk
disorder, major depression, or schizo- • Psychotic symptoms: PANSS for each 1-hr increase in average WOD
phrenia and related disorders according hours per week during competitive
to DSM–IV; aged ≥18, no severe mental employment.
retardation (IQ <60), no previous partici- Decrease in WOD hours after becoming
pation in either program, not competi- employed was significantly correlated
tively employed at intake with an increase in hours on the job.
WOD hours during competitive employ-
ment were significantly correlated with
no. of employment cycles.
No significant differences by employment

history were found.
Negative PANSS scores were significantly

correlated with average job duration (but
not total employment duration or no. of
employment cycles).
The competitive employment rate during

2.5 yr was 50% for the WOD group.
Shih et al. (2015) Level I Intervention Chu’s Attention Test Significant improvement from pretest to
Group 1: Classical light background posttest was found for Group 1 ( p = .071)
RCT music including 5 excerpts from the and Group 2 (p = .048) but not for the
N = 49 (M age = 47, 59.2% male). works of Pachelbel, Bach, and others control group.
Intervention Group 1, n = 16. Group 2: Popular background music

including 5 best-selling popular songs
Intervention Group 2, n = 17. from previous year
No background music (quiet room)
Inclusion criteria: Adults with chronic
schizophrenia; resided in halfway house
in Taipei, Taiwan; accepted into a VOC
and work-seeking program
(Continued)
A56

Smith et al. (2015) Level I Intervention Vocational The intervention group received more
• Total no. of weeks searching for job offers (47.8%) than the control
RCT VR–JIT (≤10 hr, ∼20 trials) over 5 visits employment group (14.3%) at 6 mo (p = .055).
across 5–10 business days • No. of job interviews completed Neurocognition and months since prior
N = 32.
Control • No. of job offers received and employment accounted for significantly
Intervention group, n = 21 (M age = accepted greater odds for the intervention group
40.8, 52.4% male). Wait list; TAU for 5–10 business days to receive a job offer.
Nonvocational
Control group, n = 11 (M age = 39.1, • Role-play performance: 20 min each, No significant results were found for
54.5% male). scored across 9 domains by 2 blinded completed interviews, accepted job offers
experienced raters (% of those offered), total no. of inter-
• Interviewing self-confidence: 7-point views completed, or no. of weeks search-
phrenia or schizoaffective disorder
Likert scale to answer 9 questions ing for employment. During the 6-mo
according to DSM–IV–TR, aged 18–55,
• VR–JIT process measures: each virtual period, 39% of the intervention group
minimum 6th-grade reading level using
interview scored using algorithm to and 14% of the control group received
WRAT–IV, willing to be video recorded,
assess appropriateness of responses and accepted a job offer.
unemployed or underemployed and
based on 8 domains
actively seeking a job The intervention group showed signifi-
cantly greater improvement in role-play
performance over time compared with
the control group. No significant differ-
ence in interviewing self-confidence was
found; however, the intervention group
showed a trend toward higher confi-
dence at posttest that was maintained
at 6 mo.
Regarding VR–JIT process measures, par-

ticipants showed significant improvement
over time. Completing more VR–JIT trials
correlated significantly with fewer weeks
searching for employment and greater
improvement in self-confidence. A larger
VR–JIT performance slope correlated
with greater improvement in role-play
performance.
(Continued)
A57

Tan & King (2013) Level I Intervention Vocational Intervention participants had significantly
CR combining restorative and compen- • Total no. of hours in open employ- more total hours worked and more total
RCT satory approaches with an emphasis ment (for those in vocational program salary earned than control participants at
N = 70. on generalization to daily functioning, only) 12 mo follow-up. Employment rates were
including computer-assisted cogni- • Total salary earned not reported.
Intervention group, n = 36 (M age = tive exercise drills and cognitive-based
32.7, 58.3% male). counseling Nonvocational The intervention group showed sig-
Skills attainment: nificantly greater improvement in skills
Control group, n = 34 (M age = 36.8, Control • Work performance: WBI (for those in attainment (WBI and ILS) and functioning
55.9% male). PE adapted from the structured exercise vocational program only) (MCAS) over time compared with the
program implemented by the Centre • IADLs: ILS (for those in day rehab control group .
Inclusion criteria: Clients of OT outpatient
for Psychiatric Rehabilitation at Boston program only)
rehabilitation in Singapore, participating Both groups showed significant improve-
University, consisting of exercise and Community functioning:
in VOC or day rehabilitation program, ment over time on all neurocognitive
physical-based counseling in 60 hr over • Overall level of community ability:
DSM–IV diagnosis of schizophrenia or measures (CTMT, RAVLT, WAIS) except
12 wk concurrently with VOC or day MCAS (for those in day rehab program
schizoaffective disorder, GAF score >30 the Recognition Memory subset of the
rehabilitation program (at least 1 yr and only)
3 mo total) RAVLT. The intervention group showed
Neurocognitive functioning: significantly greater improvement over
• Immediate information processing: time compared with the control group for
CTMT all measures.
• Verbal memory: RAVLT
• Attention and working memory: WAIS The control group showed significantly
greater improvement in physical fitness
Physical fitness: over time compared with the intervention
• Aerobic fitness: RWT group (RWT).
Other: Both groups showed significant improve-

• Psychotic symptoms: PANSS ment over time on the PANSS and
• QOL: WHOQOL–BREF WHOQOL–BREF. The intervention group
showed significantly greater improve-
ment over time compared with the con-
trol group on the PANSS but not on the
WHOQOL–BREF.
Tao et al. (2015) Level I Intervention Vocational For participants with reduced PANSS
CRT addressing memory, attention, lan- • Being employed or attending school scores, a significantly higher percentage
RCT guage expression, logic, execution, and for >1 mo of the intervention group was employed
N = 86. coordination integrated with psychophar- or attending school by the end of the
macological treatment 2-yr follow-up (64%) compared with the
control group (43%).
(Continued)
A58

Intervention group, n = 44 (M age = Control Nonvocational Relapse rates were significantly lower
29.0, 56.8% male). TAU (inpatient psychopharmacological • Relapse rate: increase in PANSS score for the intervention group (18%)
treatment with 1 type of 1st-generation by >25% during follow-up; significant than the control group (41%) at 2-yr
Control group, n = 42 (M age = 29.7 yr, antipsychotic over 3 mo) threat of suicide or hurting people for follow-up.
52.4% male). ≥1 wk
• Psychotic symptoms: PANSS Both groups showed significant improve-
Inclusion criteria: Hospitalized adults with ment in PANSS scores over baseline after
schizophrenia in China, met criteria for • Working memory: Digit Span Test
• Word generation: Verbal Fluency Test 3 mo of treatment.
schizophrenia according to the Chinese
Classification of Mental Disorders–3, • EF: WCST The intervention group showed
aged 18–44, education higher than significant improvement over base-
middle school, disease course <10 yr line on the Digit Span Test, Verbal
Fluency Test, and WCST compared
with the control group after 3 mo of
treatment.
A. W. Tsang et al. Level II Intervention Vocational Intervention participants achieved a

(2010) Kapok Clubhouse, a traditional • Independent, supported, transitional, higher rate of employment, compared
2 groups, nonrandomized Clubhouse model (meeting international or group transitional employment with control participants. 11 (24%)
N = 92. standards) consisting of a WOD pro- Clubhouse participants were employed
gram (gardening, catering, clerical, and Nonvocational at 6-mo follow-up: 4 in independent
Intervention group, n = 46 (M age = administrative) and access to transitional • Psychotic symptoms: PANSS employment, 3 in supported employ-
40.5, 67% male). employment, supported employment, • Chinese BDI–II ment, 2 in transitional employment, and
and group placement training • Hong Kong Chinese WHOQOL–BREF 2 in group transitional employment.
Control group, n = 46 (M age = 40.3, • Chinese RSES 1 control participant achieved open
67% male). Control • Chinese IPC employment. Independent competitive
Standard treatment at regional mental Schizophrenia relapse: employment rates during 6 mo were 9%
Inclusion criteria: Unemployed adults
health outpatient clinic • Admission to psychiatric hospital or for the intervention group and 2% for
with ICD–10 diagnosis of schizophrenia
day hospital the control group.
in Hong Kong
• Increase in antipsychotic medication
• Exacerbation of psychotic symptoms
(Continued)
A59

Intervention participants showed signifi-

cantly higher scores at baseline on the
PANSS Positive subscale, PANSS General
Psychopathology, and BDI and signifi-
cantly lower scores for physical HRQOL
and internal locus of control (IPC).
Intervention participants showed sig-

nificant improvements over control
participants for PANSS Negative, PANSS
General, and PANSS Total.
Intervention participants showed nonsig-

nificant trends toward improved scores,
and control participants showed trends
in the opposite direction, on the BDI–II,
WHOQOL, RSES, and IPC Domain I (no
change in Domains P and C).
No significant difference was found in

schizophrenia relapse rate.
Tsang et al. (2009) Level I Intervention Vocational Intervention Group 1 showed a signifi-
Group 1: ISE with IPS model augmented • No. of job interviews attended cantly higher rate of competitive employ-
RCT with social skills training; including a • No. of jobs obtained ment at 7, 11, and 15 mo compared with
N = 163. specific work-related social skills train- • Hours per week worked both Group 2 and the control group,
ing module addressing job interview • Salary received and Group 2 showed a significantly
skills and basic conversation and social • Help seeking, positive self-appraisal, higher rate of competitive employment
survival skills for effective communication work adjustment, and avoidance: compared with the control group at the
with supervisors, coworkers, and custom- 21-item CJSC (ISE and IPS only) same time points. Competitive employ-
ers; 10 group sessions • Job terminations: CJTC (ISE and IPS ment rates during 15 mo were 78.8% for
only) Group 1, 53.6% for Group 2, and 7.3%
for the control group.
(Continued)
A60

Intervention Group 1, n = 52 (M age = Group 2: Traditional IPS model including Intervention Group 1 had significantly
33.5, 50.0% male). referral, building a relationship, voca- longer job tenure than Group 2 and the
tional assessment, individual employ- control group, and Group 2 had signifi-
Intervention Group 2, n = 56 (M age = ment plan, obtaining employment, and cantly longer job tenure than the control
33.8, 51.8% male). follow-up support group.
Control group, n = 55 (M age = 36.4, Control No significant differences in job stress
47.3% male). TVR including vocational assessment, coping were found between the interven-
Inclusion criteria: Adults in Hong Kong prevocational training, and entry-level tion groups (CJSC).
with SMI (schizophrenia, schizoaffec- supervised job tasks
No significant difference in unwanted
tive disorder, bipolar disorder, recurrent job terminations was found between
major depression, or borderline personal- intervention groups, although there
ity disorder); unemployed; willing and was a trend toward fewer terminations
cognitively competent to give informed because of interpersonal problems in
consent; no obvious cognitive, learning, Group 1 (8%) compared with Group
or neurological impairments as deter- 2 (25%).
mined by mental status exam; completed
primary education; expressed desire to
work
H. W. H. Tsang et al. Level I Intervention Vocational Both intervention groups showed higher
(2010) Group 1: ISE augmented with social • No. of job interviews attended rates of successful competitive employ-
RCT skills training; a specific work-related • No. of jobs obtained ment (i.e., ≥20 hr/wk for ≥2 mo) than
N = 189. social skills training module addressing • Hours per week worked the control group at 7, 11, and 15 mo
job interview skills and basic conversa- • Salary received follow-up. Intervention Group 1 showed
Intervention Group 1, n = 58 (M age = tion and social survival skills for effective • Job terminations: CJTC significantly higher rates of employment
34.1, 44.8% male). communication with supervisors, cowork- than Group 2 at 7, 11, 15, 21, 27, 33,
ers, and customers; problem-solving and 39 mo follow-up. Only 6.1% of
approach to help participants handle control participants obtained competitive
interpersonal conflicts through follow-up employment before 15-mo follow-up.
period; OTs as employment specialists;
10 group sessions over 3 mo plus 36-mo
follow-up
(Continued)
A61

Intervention Group 2, N = 65 (M age = Group 2: Traditional IPS with integrated Nonvocational Competitive employment rates during 39
34.1, 55.4% male). mental health and employment services • Stress coping strategies in the work- mo were 82.8% for Intervention Group 1
including referral, building a relation- place: 21-item CJSC and 61.5% for Group 2.
Control, n = 66 (M age = 36.5, 47.0% ship, vocational assessment, individual • Subjective well-being: Personal
male). employment plan, obtaining employ- Wellbeing Index No significant difference was found
ment, and follow-up support, with OTs • Confidence regarding abilities to deal in job nature among the 3 groups.
Inclusion criteria: Adults with SMI in Intervention Group 1 had significantly
Hong Kong; diagnosis of schizophrenia, as employment specialists; 3 mo initial with novel or demanding situations:
Chinese General Self-Efficacy Scale longer job tenure at 7, 11, 15, and 21
schizoaffective disorder, bipolar disorder, service plus 36-mo follow-up mo compared with Group 2 (trend con-
recurrent major depression, or borderline Control tinued to 39 mo). No significant differ-
personality disorder; ≥2 yr of major role TVR including vocational assessment, ences in salary were found between the
dysfunction; medium to high functioning prevocational training, and sheltered intervention groups.
and free from serious role dysfunction workshop–based training, over 15 mo
for past 3 mo; unemployed; willing and Average no. of unwanted job termi-
cognitively competent to give informed nations was significantly higher for
consent; completed primary education; Intervention Group 1 than for Group
desired to work 2 at 7, 11, and 15 mo (trend contin-
ued to 39 mo). Group 2 participants
experienced significantly more work-
place interpersonal difficulties result-
ing in job termination than Group 1
participants.
No significant group differences

were found on the CJSC or Personal
Wellbeing Index. On the Chinese
General Self-efficacy Scale, the interven-
tion groups scored significantly higher
than the control group at 15 mo, with
no significant difference between treat-
ment groups.
Tsang & Man (2013) Level I All participants received similar prevoca- Primary Intervention Group 1 showed no signifi-
tional skills training in work-simulated Nonvocational cant improvements compared with the
RCT workshops in the OT department. Cognitive: control group in BNCE (general cogni-
N = 95 (75 completed the study). • General cognitive profile: BNCE tion), DVT (attention), or RBMT (memory)
• Functional abilities to successfully scores.
cope with an independent living
situation
(Continued)
A62

Intervention Group 1, n = 25 (M age = Intervention • Sustained attention and psychomotor On the WCST (EF), significant results
39.6, 28% male). Group 1: VRG consisting of top-down speed during rapid visual tracking: were found for percentage of errors for
cognitive training (simultaneously DVT group effect and Group × Time effect,
Intervention Group 2, n = 25 (M age = emphasizes multiple cognitive domains, • Memory problems: RBMT percentage of preservative errors for time
40.8, 60% male). with different procedures and strategies) • EF: WCST Computer Version 4 effect, and percentage of conceptual-
Control, n = 25 (M age = 41.6, 44% and virtual reality–based vocational skills level responses for group effect and
training in a virtual boutique scenario, 10 Vocational Group × Time effect. Intervention
male). • Cognitive functioning at work: VCRS Group 1 showed significantly better
30-min sessions over 5 wk
Inclusion criteria: Inpatient adults with Secondary improvement than the control group in
diagnosis of schizophrenia in Hong Kong, Group 2: TAG vocational skills training percentage of errors and percentage of
program in a boutique, 10 30-min ses- • Knowledge and skills in performing
attended VOC services at a hospital OT sales-related activities (self-designed): conceptual-level responses.
department, Chinese ethnicity, aged sions over 5 wk
On-Site Work Performance Test On the VCRS (cognitive functioning in
18–55, able and willing to provide Control • Self-efficacy in performing sales-
informed consent work), Intervention Group 1 experienced
Conventional group (not specifically related activities (self-designed): no statistical improvement over the con-
described) Perceived Work Performance trol group.
Self-Efficacy
On the On-Site Work Performance Test,
significant results were found for time
effect and Group × Time effect; both
intervention groups showed significantly
better improvement than the control
group.
Regarding Perceived Work

Performance Self-Efficacy, significant
results were found for time effect;
Intervention Group 1 showed signifi-
cantly better improvement than the
control group.
Twamley et al. (2008) Level I Intervention Vocational The intervention group showed significantly
Supported employment with IPS model, • Obtained competitive employment better outcomes compared with the control
RCT including vocational specialist, assess- • Total hours worked group for obtaining competitive employ-
N = 50. ment, job search assistance, and time- • Total income earned ment, total hours worked, and total income
unlimited follow-along support • Time to 1st employment
(Continued)
A63

Intervention group, n = 28 (M age = Control Nonvocational earned. Competitive employment during

50.0, 71% male). CVR with assigned VOC counselor and • QOLI 12 mo was 57% for the intervention group
additional staff for job coaching and • AIMS and 27% for the control group.
Control group, n = 22 (M age = 51.1, training, evaluation, education, and skills • PANSS
46% male). development • HAM–D Participants in either group who
obtained competitive employment
Inclusion criteria: Aged ≥45, DSM–IV showed a significant increase in QOLI
diagnosis of schizophrenia or schizoaf- scores compared with those who did
fective disorder, receiving outpatient not obtain employment. Those who
psychiatric care, unemployed but wanted obtained competitive work were more
to work likely to be receiving intervention
than control services and had worked
more recently in the past, but they did
not differ on any other variables at
baseline.
Twamley et al. (2012) Level I Intervention Vocational The intervention group showed signifi-
Supported employment with IPS model, • Obtained competitive employment cantly better outcomes compared with
RCT including manualized supported employ- • Obtained any paid employment the control group for obtaining competi-
N = 58. ment intervention from an employment • Total hours worked tive employment, obtaining any employ-
specialist emphasizing competitive work • Total income earned ment, total hours worked (competitive
Intervention group, n = 30 (M age = and integrated mental health and sup- • Time to 1st employment and any), and total income earned (com-
50.0, 73.3% male). ported employment services petitive and any). Competitive employ-
Nonvocational ment rates during 12 mo were 57% for
Control group, n = 28 (M age = 51.1, Control • Functional capacity in 5 domains the intervention group and 29% for the
53.6% male). CVR, with a vocational counselor and (household chores, communication, control group.
additional staff for job readiness and pre- finance, transportation, planning
Inclusion criteria: Aged ≥45, DSM–IV
vocational coaching and classes recreational activities): UPSA For the intervention group, higher total
diagnosis of schizophrenia or schizoaf-
• AIMS scores on the UPSA (higher level of base-
fective disorder, receiving outpatient
• PANSS line function) were significantly positively
psychiatric care, unemployed but wanted
• HAM–D correlated with attainment of competitive
to work
work, and time since last job was signifi-
cantly negatively correlated with attain-
ment of, weeks of, and wages earned
from competitive employment.
For the control group, higher HAM–D

scores (more severe depressive symp-
toms) were significantly negatively
correlated with attainment of, weeks

of, and wages earned from competitive
employment.
A64
(Continued)

van Veggel et al. (2015) Level II Intervention Primary The intervention group showed sig-
Supported employment with IPS model • ≥1 days of competitive employment in nificantly better outcomes in obtaining
2 groups, nonrandomized integrated within community health sites past 12 mo, defined by IPS competitive employment compared with
N = 586. colocating a full-time employment spe- the control group. This difference was
cialist into the premises of each mental Secondary greater for those who had an initial goal
Intervention group, n = 446 (M age = health service • Commenced any vocational activity of competitive employment. Competitive
39.6, 56.3% male). • Commenced any vocational activity employment rates during 12 mo were
Control other than competitive employment 24.9% for the intervention group and
Control group, n = 140 (M age = 39.4, CVR provided by an OT as a member of • ≥13 wk employment 14.3% for the control group.
54.3% male). the community mental health team • ≥26 wk employment
• Mean days to 1st job On average, intervention participants
Inclusion criteria: Adult clients at 17
• Mean hours worked per week worked more hours per week, reduced
mental health sites in Britain who
time to 1st job by ∼5 mo, and increased
expressed a vocational goal to a mental
hours worked per week by 9 hr com-
health team member
pared with control participants. The
control group performed better on voca-
tional outcomes other than competitive
employment.
Waghorn et al. (2014) Level I Intervention Primary The intervention group showed sig-
ISE with IPS model integrated within • ≥1 days of competitive employment, nificant positive differences over all 4
RCT community health centers with full-time defined by IPS sites combined in obtaining competitive
N = 208. employment specialist who was colo- • Any vocational benefit employment at 6 and 12 mo compared
cated at mental health services 4–5 days/ • Commencement of formal employ- with the control group. Separately, only
IPS group, n = 106. wk while also maintaining contact with ment, education, or training 1 site showed a significant difference.
parent employment service and who Competitive employment rates during
Control group, n = 102. Secondary
received specific training in evidence- 12 mo were 42.5% for the intervention
based practice and linking community • Job duration in weeks group and 23.5% for the control group.
Inclusion criteria: Adults with SMI in
sites to employment sites • Hours worked per week
Australia, aged 18–59, interested in
• Earnings The intervention group showed signifi-
competitive employment as a goal, able
Control • Job diversity cant positive differences over all 4 sites
to work ≥8 hr/wk, not employed cur-
Nonintegrated supported employment combined for obtaining any vocational
rently or within past 3 mo, diagnosis of
with case managers from mental health benefit compared with the control group.
psychotic disorder, consumer of mental
services who acted as facilitators to link Separately, no sites showed a significant
health service at time of referral, not in
clients with employment service and who difference.
acute phase of illness, living in mental
received specific training in evidence-
health service catchment area with no No significant differences were found in
based practice and linking community
immediate plans to move, considered secondary outcomes.
sites to employment sites
by clinical team to be able to safely
participate
(Continued)
A65

Watzke et al. (2009) Level II Intervention Vocational The intervention group showed signifi-
SVR consisting of training in work skills • Permanent vocational disability cantly more participation in competitive
2 groups, nonrandomized (e.g., math, computers, bookkeeping), • Unemployed employment or regular apprentice-
N = 181. social skills, and management of daily • Sheltered workplace or VOC ship (18.9%) and sheltered workplace
activities in work simulation or sheltered • Regular employment or apprenticeship employment or VOC (20.8%) at 9-mo
Intervention group, n = 106 (M age = environments, M duration 10 mo follow-up compared with the control
33.1, 41.5% male). Nonvocational group (competitive, 16.0%; sheltered,
Control • Psychiatric symptoms: PANSS 2.7%).
Control group, n = 75 (M age = 33.9, TAU (no vocational intervention; stan- • General functioning: LoF
42.7% male). dard psychiatric outpatient care) • Subjective well-being: Psychological The intervention group had significantly
Well-Being subscale of German higher scores on the PANSS, LoF, and
Inclusion criteria: Unemployed adults
WHOQOL WHOQOL at each time point (including
with SMI in Germany
baseline) compared with the control
group. PANSS and WHOQOL scores
improved over time for both groups
(PANSS score differences were not clini-
cally significant). LoF scores improved
significantly more in the intervention
group.
Note. Participant ages are expressed in years unless otherwise noted. AIMS = Abnormal Involuntary Movement Scale; BACS–J = Brief Assessment of Cognition in Schizophrenia–Japanese version; BDI = Beck Depression
Inventory; BNCE = Brief Neuropsychological Cognitive Examination; BPRS = Brief Psychiatric Rating Scale; BVMT–R = Brief Visuospatial Memory Test–Revised; CACR = computer-assisted cognitive rehabilitation; CAT =
cognitive adaptive training; CBT = cognitive–behavioral therapy; CI = confidence interval; CJSC = Chinese Job Stress Coping Scale; CJTC = Chinese Job Termination Checklist; CPT = Continuous Performance Test; CPT–IP
= Continuous Performance Test, Identical Pairs version; CR = cognitive remediation; CRT = cognitive rehabilitation/remediation training; CTMT = Comprehensive Trail Making Test; CVLT = California Verbal Learning Test;
CVR = conventional vocational rehabilitation; DPA = Diversified Placement Approach; DSM = Diagnostic and Statistical Manual of Mental Disorders; DVT = Digit Vigilance Test; EF = executive function; ESE = enhanced
supported employment; GAF = Global Assessment of Functioning; GDP = gross domestic product; HAM–D = Hamilton Rating Scale for Depression; HRQOL = health-related quality of life; HVLT–R = Hopkins Verbal
Learning Test–Revised; IADLs = instrumental activities of daily living; ICD = International Statistical Classification of Diseases and Related Health Problems; ILS = Independent Living Scales; IPC = Internality, Powerful Others,
and Chance Multidimensional Locus of Control Scale; IPS = Individual Placement and Support; ISE = Integrated Supported Employment; IVIP = Indianapolis Vocational Intervention Program; LASMI = Life Assessment
Scale for the Mentally Ill; LoF = Level of Functioning; M = mean; MANSA = Manchester Short Assessment of Quality of Life; MATRICS = Measurement and Treatment Research to Improve Cognition in Schizophrenia;
MCAS = Multnomah Community Ability Scale; MIRRORS = Mindfulness Intervention for Rehabilitation and Recovery in Schizophrenia; MMSE = Mini-Mental State Examination; MWS = Makuhari Work Sample; NAB =
Neuropsychological Assessment Battery; NEAR = Neuropsychological Educational Approach to Remediation; NET = neurocognitive enhancement therapy; NSA–M = Negative Symptom Assessment–Motivation subscale;
OT = occupational therapy/therapist; OT–PVP = OT-led prevocational program; PANSS = Positive and Negative Syndrome Scale; PE = physical exercise; QLS = Quality of Life Scale; QOL = quality of life; QOLI = Quality of
Life Interview; RAVLT = Rey Auditory Verbal Learning Test; RBMT = Rivermead Behavioural Memory Test; RCT = randomized controlled trial; RSES = Rosenberg Self-Esteem Scale; RTW = return to work; RWT = Rockport
Walking Test; SD = standard deviation; SMI = serious mental illness; SOFAS = Social and Occupational Functioning Assessment Scale; SSDI = Social Security disability income; SSI = supplemental security income; SVR =
standard vocational rehabilitation; TAG = therapist-administered group; TAU = treatment as usual; Trails A = Trail Making Test Part A; Trails B = Trail Making Test Part B; TSW = Thinking Skills for Work program; TVR = tra-
ditional vocational rehabilitation; TVS = traditional vocational services; UPSA = University of California, San Diego, Performance-Based Skills Assessment; VCRS = Vocational Cognitive Rating Scale; VOC = vocational train-
ing/rehabilitation; VRG = virtual reality–based vocational training group; VR–JIT = virtual reality job interview training; WAIS = Wechsler Adult Intelligence Scale; WAIS–R = Wechsler Adult Intelligence Scale–Revised; WBI
= Worker Behavior Inventory; WCST = Wisconsin Card Sorting Test; WHOQOL = World Health Organization Quality of Life Scale; WHOQOL–BREF = abbreviated version of WHOQOL; WOD = work-ordered day; WRAT =
Wide Range Achievement Test; WRAT–R = Wide Range Achievement Test–Revised.
Source. Noyes, S., Sokolow, H., & Arbesman, M. (2018). Evidence for occupational therapy intervention with employment and education for adults with serious mental illness: A systematic review (Suppl. Table 1).
American Journal of Occupational Therapy, 72, 7205190010. https://doi.org/10.5014/ajot.2018.033068
A66
Table A.5. Risk-of-Bias Analysis for Intervention Studies Included in the Systematic Review of Interventions to Support Employment and Education for Adults
Living With SMI
Incomplete Outcome Data

Selection Bias Detection Bias (Attrition Bias)
Blinding of Selective
Participants Blinding of Blinding of Reporting
Random Sequence Allocation and Personnel Patient-Reported Objective Short Term Long Term (Reporting
Citation Generation Concealment (Performance Bias) Outcomes Outcomes (2–6 wk) (>6 wk) Bias)
Areberg & Bejerholm + + + + + + + +

(2013)
Au et al. (2015) + + + + + + + +
Bell et al. (2008a) + ? – + – + + +
Bell et al. (2008b) + + + + – + + +
Bio & Gattaz (2011) + ? ? + + + + +
Bond, Kim, et al. + + + + – + + +

(2015)
Burns et al. (2009) + ? ? + – + + +
Catty et al. (2008) + + ? + – + + +
Chuang et al. (2015) – – – + – + + +
Cook et al. (2008) ? ? + + – + + +
Cook et al. (2016) + + + + – + + +
Davis et al. (2015) ? ? – + – + + +
Eack et al. (2011) + + + + – + + +
Gutman et al. (2009) ? ? + + + + + +
Hees et al. (2013) + + + + + + + +
Heslin et al. (2011) + + ? + – + + +
Hodge et al. (2010) + + – + – + + +
Hoffmann et al. (2012) + + – + – + + +
Hoffmann et al. (2014) + + – + – + + +
A67
Howard et al. (2010) + + + + – + + +
(Continued)

Kidd et al. (2014) + + ? ? – + + +
Kin Wong et al. (2008) + ? – + – + + +
Kukla & Bond (2013) + – – + – + + +
Kukla et al. (2014) + ? – + – + – +
Lee (2013) + + + + + + + +
Lysaker et al. (2009) + + + + + + ? +
McGurk et al. (2009) + + + + + + ? +
McGurk et al. (2010) – – – + – + + +
McGurk et al. (2015) + + + + + + + +
Michon et al. (2014) + + ? + + + ? +
Mueser et al. (2014) + ? ? + – + + +
Poremski et al. (2017) + – – + – + + +
Quee et al. (2014) – ? + + + ? + +
Rouleau et al. (2009) – – – + – + + +
Sato et al. (2014) – + ? + – + + +
Schonebaum & Boyd ? – – + – + + –

(2012)
Shih et al. (2015) + ? – + – + + +

Smith et al. (2015) + – – ? + + + ?
Tan & King (2013) + + + + + + + +
A68
(Continued)

Tao et al. (2015) + ? – + – + ? ?
A. W. Tsang et al. – – – + – + + +
(2010)
H. W. H. Tsang et al. + + ? + + + + +
(2009)
H. W. H. Tsang et al. + + ? + + + ? +
(2010)
M. M. Y. Tsang & + + + + + ? ? +
Man (2013)
Twamley et al. (2008) + ? ? + + + ? +
Twamley et al. (2012) + ? ? + + + ? +
van Veggel et al. (2015) – – – + – + ? +
Waghorn et al. (2014) + ? – + + + ? +
Watzke et al. (2009) – – – + – + – +
Note. Categories for risk of bias are as follows: + = low risk of bias; ? = unclear risk of bias; – = high risk of bias.
Risk-of-bias table format adapted from “Assessing Risk of Bias in Included Studies,” by J. P. T. Higgins, D. G. Altman, and J. A. C. Sterne, in Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0), by J.
P. T. Higgins and S. Green (Eds.), 2011, London: Cochrane Collaboration. Retrieved from http://handbook-5-1.cochrane.org. Copyright © 2011 by The Cochrane Collaboration.
Source. Noyes, S., Sokolow, H., & Arbesman, M. (2018). Evidence for occupational therapy intervention with employment and education for adults with serious mental illness: A systematic review (Suppl. Table 2).
A69
Table A.6. Risk-of-Bias Analysis for Systematic Reviews Included in the Systematic Review of Interventions to Support Employment and Education for Adults
Living With SMI
Duplicate
Study Comprehensive Status of List of Included/ Characteristics Quality Likelihood of Conflict
A Priori Selection/ Literature Publication Excluded of Included of Studies Methods Used to Publication of
Design Data Search as Inclusion Studies Studies Assessed and Quality Assessment Combine Results Bias Interest
Citation Included? Extraction? Performed? Criteria? Provided? Provided? Documented? Used Appropriately? Appropriate? Assessed? Stated?
Arbesman & + + + + + + + + NA – +
Logsdon (2011)
Bond et al. (2008) + – + + + + + + + + –
Campbell et al. + – ? ? + + + + + ? +
(2011)
Campbell et al. + + + – + + + + + – –
(2010)
Chan et al. (2015) + + + + + + + + + + +
Gibson et al. (2011) + + + + – – + + NA – +
Kinoshita et al. + + + + + + + + + + +
(2013)
Modini et al. (2016) + + + – – ? + + + + ?
Note. Risk-of-bias categories: + = low risk of bias; ? = unclear risk of bias; – = high risk of bias. NA = not applicable.
Hamel, . . . L. M. Bouter, 2007, BMC Medical Research Methodology, 7, p. 10. https://doi.org/10.1186/1471-2288-7-10
This table is a product of AOTA’s Evidence-Based Practice Project and the American Journal of Occupational Therapy. Copyright © 2018 by the American Occupational Therapy Association. It may be freely reproduced for per-
sonal use in clinical or educational settings as long as the source is cited. All other uses require written permission from the American Occupational Therapy Association. To apply, visit http://www.copyright.com.
Source. Noyes, S., Sokolow, H., & Arbesman, M. (2018). Evidence for occupational therapy intervention with employment and education for adults with serious mental illness: A systematic review (Suppl. Table 3). American
Journal of Occupational Therapy, 72, 7205190010. https://doi.org/10.5014/ajot.2018.033068
A70
Table A.7. Evidence Table for the Systematic Review of Interventions to Promote Health and Wellness for Adults Living With SMI

Physical Health
Bartels, Pratt, Mueser, Level I Intervention • Attendance The intervention group showed greater
Naslund, et al. (2014) Integrated Illness Management and • Illness Management and Recovery preference for receiving detailed diagnosis
RCT Recovery program combining com- Scales and treatment information during medical
N = 71. ponents of illness management and • Stanford Chronic Disease Self-Efficacy visits than the control group (p = .004).
recovery related to psychiatric illness Scale
Intervention group, n = 36 (M age = self-management with self-management • BPRS At 10-mo follow-up, the intervention
60.5, 47% male). strategies for general medical illness • MCAS group had no hospitalizations during
plus a nurse health care manager com- • Stanford Physician Communication the prior 3 mo compared with 25% of
Control group, n = 35 (M age = 60.1, control participants.
ponent plus TAU, 10 weekly modules Scale, Communication Role subscale
43% male).
over 8 mo • Autonomy Preference Index, At 14-mo follow-up, 17% of interven-
Inclusion criteria: Aged ≥50; enrolled Information Seeking Preference and tion participants had been hospitalized
Control Decision Making Preference subscales
in treatment at a community mental during the prior 3 mo compared with
TAU • Self-reported hospitalizations and
health center ≥3 mo; diagnosis of SMI 25% of control participants.
and diabetes, chronic obstructive pulmo- emergency visits
nary disease, congestive heart failure, The intervention group showed
ischemic heart disease, hypertension, decreases in self-reported psychiatric or
hyperlipidemia, or osteoarthritis medical hospitalizations compared with
the control group ( p = .037).
No differences between groups were

found for improvement in psychiatric
symptom severity and community function-
ing or for self-reported emergency visits.
Battersby et al. (2013) Level I Intervention AUDIT The intervention group showed
Flinders Program, Alcohol Practice improved (lower) AUDIT scores com-
RCT Guidelines and self-help materials such pared with the control group by an aver-
N = 77. as The Right Mix—Your Health and age of 0.32 for every additional month
Alcohol, and 6 wk of weekly 2.5-hr from baseline to 9 mo ( p = .039).
Intervention group, n = 46 (M age = group sessions of SCDSMP, conducted
60.55). over 9 mo, plus TAU The control group had 1.46 times greater
risk of alcohol dependence at 9-mo follow-
Control group, n = 31 (M age = 60.18). Control up than the intervention group ( p = .027).
TAU
Inclusion criteria: Vietnam veterans, The intervention group showed a signifi-
AUDIT score ≥8, chronic condition, eli- cant decrease in alcohol dependence from
gible for veteran medical benefits 64% of participants at baseline to 41%
at 9 mo ( p = .004) compared with the
control group, in which 48% identified as
alcohol dependent at both time points.
A71
(Continued)
Table A.7. Evidence Table for the Systematic Review of Interventions to Promote Health and Wellness for Adults Living With SMI (cont.)

Bradford et al. (2013) Level I Intervention • SF–36 Physical Component Summary 2 studies found that integrated care inter-
Interventions focused on improving gen- • SF–12 ventions were associated with increased
Systematic review eral medical outcomes and on psychi- • WHO–DAS rates of immunization and screening.
N = 4 RCTs. atric care enrollment and collaboration; • RAND Community Quality Index
care management and care coordination • Framingham Cardiac Index 2 studies found small improvements in
Inclusion criteria: RCT or quasi-experi- were common goals the Physical Component Summary of the
mental design; adult outpatient samples SF–36 and SF–12.
with ≥25% of participants with SMI; Control
TAU 2 studies found no significant difference
intervention goal to improve medical in SF–36 scores.
outcomes through integration of care;
control condition of usual care; out- No studies reported clinical outcomes
comes assessing process of care, clinical related to preventive care or chronic
outcomes, or physical functioning medical care.
Chafetz et al. (2008) Level I Intervention • SF–36 The intervention group reported sig-
Wellness training; a self-administered • Self-rating of current health-related nificant improvement in self-reported
RCT individualized training program to pro- problems general health status associated with
N = 309. mote skills in self-assessment, self-moni- • GAF less severity of illness and less reported
toring, and self-management of physical drug use, whereas the control group
Intervention group, n = 155 (M age = health problems, available for up to 12 showed decreased general health scores
38.5, 68.4% male). mo; plus basic primary care ( p = .006).
Control group, n = 154 (M age = 38.0, Control
67.5% male). Basic primary care including health
assessments, immediate or short-term
Inclusion criteria: Residents of crisis residen-
care, health education, and referrals
tial units in San Francisco with SMI, English
speaking, no dementia or acute illness
Druss et al. (2010) Level I Intervention • PAM Higher patient activation was found in
Health and Recovery Peer program, an • BRFSS the intervention group than in the con-
RCT adaptation of the CDSMP, consisting of • Self-reported medication adherence trol group at 6 mo ( p = .03).
N = 80. 6 group sessions covering topics related • SF–36
to chronic disease self-management The intervention group had more reported
Intervention group, n = 41 (M age = administered by 2 mental health peer visits to a primary care physician, with an
47.8, 34.1% male). specialists 8.3% improvement, compared with a
17.1% decline in the control group ( p = .04).
25.6% male). TAU The intervention group improved in
medication adherence, whereas the con-
Inclusion criteria: Active patients at a trol group showed a decline ( p = .22).
community mental health center with
SMI and ≥1 chronic medical condition The intervention group scored higher at
6 mo on the SF–36 Physical Component
Summary than the control group ( p = .41).
A72
(Continued)

Goldberg, Dickerson, Level I Intervention • SF–12 The intervention group showed significant
et al. (2013) Living Well, an intervention adapted • Self-Management Self-Efficacy Scale improvements on the Physical Functioning,
RCT from the CDSMP, focused on SMI self- • PAM Emotional Well-Being, and General Health
N = 63. management through action planning, • Multidimensional Health Locus of subscales of the SF–12 compared with the
peer feedback, modeling, and problem Control
control group ( p = .05).
Intervention group, n = 32 (M age = solving, then applying skills, 13 weekly • Recovery Assessment Scale–Short
46.7, 44% male). 60- to 75-min sessions delivered by peer Form The intervention group had higher mean
facilitators • Instrument to Measure scores on the Self-Management Self-
Control group, n = 31 (M age = 49.3, Efficacy Scale and on the Activation Level
Self-Management
52% male). Control and Approach to Health Care subscales
• Morisky Medication Adherence Scale
TAU of the PAM, whereas the control group
Inclusion criteria: Diagnosis of SMI and
worsened or stayed the same ( p < .05).
≥1 chronic general medical condition
On the Instrument to Measure
Self-Management, the intervention
group improved on the General Self-
Management Behaviors ( p = .036)
and Making Better Use of Health Care
subscales ( p = .004) compared with the
control group. The intervention group
had higher scores than the control group
on the Physical Activity ( p = .048) and

Healthy Eating subscales ( p = .019).
No differences between groups were

found on the Accessing Social Support
and Behavioral and Cognitive Symptom
Management subscales or in medication
adherence.
Kelly et al. (2017) Level I Intervention • Service Engagement Scale The intervention group preferred primary
The Bridge program, in which mental • Working Alliance Inventory short form care physicians more than the control
RCT health peers teach skills to access and • Peer-recorded intervention fidelity group ( p = .045).
N = 151. manage health care and connect people • 2 scales from UCLA CHIPTS
to preventive, primary, and specialty • Engagement With Health Care The intervention group increased number
Intervention group, n = 76 (M age = health care services, 3 phases, with Provider Scale of visits to primary care physicians com-
44.8, 53.9% male). 6-mo intervals between assessments • Mental Health Confidence Scale pared with the control group ( p = .200).
• SF–12 The intervention group reported higher-
38.7% male). Wait list, TAU quality relationships with primary care phy-
sicians than the control group ( p = .004).
Inclusion criteria: Local residents ≥3 mo,
aged >18, diagnosis of SMI, English Significant reductions were found in pain
speaking, admitted to a program at study severity ( p = .005) and pain index
( p = .009) favoring the intervention group.
A73
site
(Continued)

Kelly, Fenwick, et al. (2014) Level I Intervention • Health Care Efficacy Scale 5 of 8 studies that included self-man-
Collaborative and integrated care mod- • Revised Self-Efficacy Scale agement found significant improvement
Systematic review els that include self-management train- • Independent Living Skills Survey in self-reported self-management.
N = 14 studies. ing to improve general medical health • PAM
and health care for people with SMI; • LSMECD 1 study reported significant postinter-
Inclusion criteria: RCTs and within- all studies used patient education, and • Multidimensional Health Locus of vention physical health improvement,
person pre–post studies; interventions interventions were delivered by nursing Control 1 reported clinically relevant physical
with self-management of health or staff, peers, or mental health specialists • Partners in Health health improvement in a pilot test, and
health care identified as a compo- • Gordian Personal Health Analysis 3 did not have significant results.
nent; participants with schizophrenia, • Framingham Cardiovascular Risk 1 study found significant differences
schizoaffective disorder, bipolar disor- Index between groups on the Gordian
der, or MDD • SF–12 Personal Health Analysis.
• SF–36
In 1 study, the intervention group had
significantly reduced pain compared
with the control group.
3 studies reported significantly more

visits to primary care providers by inter-
vention participants.
Kelly, Fulginiti, et al. (2014) Level I Intervention • Short-Form Six-Dimension health The intervention group had fewer symp-
The Bridge program, in which peer navi- index toms than the control group (p < .10).
RCT (pilot trial) gators teach skills to access and man- • UCLA CHIPTS
age health care and connect people to • Self-reported prescribed medications The intervention group reported less
N = 23. pain (p < .05) and less interference from
preventive, primary, and specialty health • Health Care Efficacy Scale
Intervention group, n = 12 (M age = care services, 2 phases over 6 mo pain while doing normal work (p < .01),
49.58, 58.3% male). whereas the control group did not expe-
Control rience significant changes in pain.
Control group, n = 11 (M age = 43.73, Wait list, TAU
54.5% male). In the intervention group, the proportion
of participants seeking health care from
Inclusion criteria: Residents in Los primary care physicians increased from
Angeles ≥3 mo, aged 18–60, diagnosis 50.0% at baseline to 83.3% at 6 mo
of SMI, in a publicly funded setting (p < .05). The control group showed no
changes in preferred locus of care.
No difference was found between

groups in health care efficacy scores.
(Continued)
A74

Lambert et al. (2007) Level I Intervention BAI Significant differences were

Occupational therapy–led lifestyle found between groups in BAI
RCT (unblinded pragmatic trial) program addressing diet, fluid intake, Neurophysiological ( p = .002),
N = 117. exercise, and habitual lifestyle drug use Subjective ( p < .001), and Autonomic
(caffeine, alcohol, nicotine), 10 sessions ( p = .006) subscores but not in Panic
Intervention group, n = 57 (M age = over 16 wk subscores ( p = .041) at 20 wk.
40.1, 31.6% male).
Control More intervention than control partici-
Control group, n = 60 (M age = 38.6, Unrestricted routine general practice pants remained improved in mean BAI
31.7 male). care scores from baseline to 10 mo ( p = .016).
Inclusion criteria: Aged >18, patients in
15 general practices, diagnosis of panic
disorder with or without agoraphobia,
stable dosage of medications ≥4 wk
Ludman et al. (2013) Level I Intervention • Telephone interview A higher percentage of intervention
TEAMcare combining self-care support • SCL–20 participants than control participants
RCT and collaborative care management to • Blood pressure reported improved ability to maintain
N = 214 (M age = 56.8, 48% male). improve depressive symptoms and gly- • HbA1c lifestyle changes even during times of
cemic, blood pressure, and lipid control, • Fasting low-density lipoproteins stress ( p < .001).
Intervention group, n = 106. delivered over 12 mo by nurses • PAM
A higher percentage of intervention
Control group, n = 108. Control participants than control participants
TAU reported confidence in ability to follow
Inclusion criteria: PHQ–9 score ≥10,
through on medical regimens ( p = .056).
poorly controlled diabetes or coronary
heart disease
Siantz & Aranda (2014) Level I Intervention • SF–12 5 studies reported significant changes in
CDSM programs for people with SMI • SF–36 functional status.
Systematic review • WHO–DAS
• PAM 5 studies reported significant improve-
N = 10 studies. ments in self-management attitudes.
• Perceived Self-Efficacy for Managing
Inclusion criteria: RCTs and single-sub- Chronic Conditions scale 6 studies reported improvement in self-
ject studies, CDSM intervention, clinical • Diabetes Empowerment Scale management behaviors.
outcome evaluated, at least half of • Problems in adherence to medication
participants with SMI aged >18, study scale 3 studies found improvements in anthro-
conducted in United States • Block Brief 2000 pometric outcomes.
• BRFSS
• Anthropometric measures
(Continued)
A75

Tosh et al. (2011) Level I Intervention • SILVA Pedometer plus 1 study reported no significant differ-
General health advice using health • Incremental Shuttle Walk Test ence between groups in moderate or
Systematic review promotion sessions; skills promotion in • Borg Rating of Perceived Exertion vigorous physical activity.
N = 7 RCTs. self-assessment, self-monitoring, and Scale
self-management of physical health • Metabolic syndrome defined by 1 study reported no significant differ-
Inclusion criteria: RCTs focused on gen- problems; management skills for chronic the National Cholesterol Education ence in QOL.
eral physical health advice for people illness, pain, fatigue, exercise, diet, and Program 1 study reported that significantly more
with SMI medication • Lehman Quality of Life Scale people who received physical health advice
• SF–36 attended primary care appointments.
• USPSTF grade
• Health Service Utilization Inventory 1 study reported no significant differ-
ence between groups in general health
service expenses.
Van Hasselt et al. (2013) Level I Intervention • BDI The effect of similar interventions was
Programs addressing health educa- • Posttraumatic Stress Disorder Checklist evaluated with mutually incomparable
Systematic review tion, exercise, smoking cessation, and • Framingham Risk Score measures, making it impossible to com-
N = 22 studies. changes in health care organization • SF–36 pare outcome effects and aggregate the
• Baecke Questionnaire results.
Inclusion criteria: Original prospective • Lehman Quality of Life interview
randomized studies, interventions to • Dietary Instrument for Nutrition
improve somatic health in people with Education questionnaire
SMI • Health-related self-efficacy
Whiteman et al. (2016) Level I Intervention • SCDSES 4 studies found self-management atti-
Interventions targeting SMI and general • SF–12 tudes significantly increased.
Systematic review medical illnesses that require ongoing • SF–36
treatment; 70 different outcome mea- • BPRS 1 study reported qualitative evidence of
N = 15 studies. improved self-management attitudes.
sures were used in these studies • PAM
Inclusion criteria: RCTs and pre–post • ILS 4 studies of integrated self-management
studies, self-management interventions • State Behavioral Scale interventions found significant improve-
addressing general and medical psy- • SANS ments in biological outcomes related to
chiatric self-management, participants • GDS risk factors for premature mortality.
aged ≥18 with diagnosis of SMI and a • MMSE
chronic medical illness • UPSA
• MCAS
• RSES
• Self Rated Abilities for Health
Practices Scale
• WHO–DAS
• LSMECD
A76
• CAS
(Continued)

Relaxation
Balasubramaniam Level I Intervention • Self-reported change Grade B evidence supports the potential
et al. (2013) Yoga alone or in combination with • Scores on rating scales (e.g., PANSS, acute benefit of yoga in people with
Systematic review medication TRENDS, SOFS) depression and as an adjunct to medica-
N = 16 RCTs. • Acceptability tions in people with schizophrenia and
Control • Tolerance of treatment ADHD.
Inclusion criteria: RCTs with any Other form of exercise, Ayurveda, phar-
subtype of yoga as the interven- maceutical treatment Grade C evidence supports the benefit
tion; participants with depression, of yoga for sleep complaints.
schizophrenia, ADHD, eating disor-
ders, sleep, or conditions affecting
cognition
Behere et al. (2011) Level I Intervention • PANSS At 2-mo follow-up, Intervention Group
Group 1: Yoga training by trained instruc- • SOFS 1 showed significant changes in positive
RCT (3 groups) tor for 1 mo, then 2 mo of yoga practice • T RENDS symptoms ( p = .002), negative symp-
N = 66. at home, and continued stable dose of toms ( p < .001), TRENDS scores
antipsychotic medications; caregivers ( p = .03), and SOFS scores ( p < .001).
Intervention Group 1, n = 27 (M age = were instructed to monitor practice yoga
31.3, 66.7% male). sessions at home and keep a log At 4-mo follow-up, Intervention Group
1 showed significant changes in posi-
Intervention Group 2, n = 17 (M age = Group 2: Exercise training by trained tive symptoms ( p = .008) and negative
30.2, 82.4% male). yoga instructor for 1 mo, then 2 mo of symptoms ( p = .002).
yoga practice at home, and continued
Control group, n = 22 (M age = 33.6, Intervention Group 2 and the control
stable dose of antipsychotic medications
68.2% male). group showed no significant changes.
Control
Inclusion criteria: Diagnosis of
No intervention, stable dose of antipsy-
schizophrenia confirmed by qualified
chotic medications
psychiatrist, on regular follow-up and
willing to give consent, on stabilized
antipsychotic medications ≥6 wk, CGI
score ≤3
(Continued)
A77

Chan et al. (2012a) Level I Intervention • HDRS Improved overall depressive symptoms
Group 1: CBT sessions consisting of pro- • 21-item BDI–II (HDRS) were found for Intervention
RCT (3 groups) gressive muscle relaxation, behavioral • Concentration (Digit Vigilance Test) Group 1 ( p < .001) and Intervention
N = 50. activation, self-monitoring, cognitive • Gastrointestinal Symptoms Group 2 ( p < .001).
restructuring, cognitive techniques, Questionnaire
Intervention Group 1, n = 17 (M age = rehearsal of coping skills, and relapse Improved self-rated depressive
46.94, 23.5% male). prevention led by a clinical psychologist; symptoms (BDI–II) were found for
10 weekly 90-min sessions Intervention Group 1 ( p < .001),
Intervention Group 2, n = 17 (M age = Intervention Group 2 ( p < .001), and
47.06, 11.8% male). Group 2: Dejian Mind–Body Intervention the control group ( p = .019).
sessions consisting of “listening to your
Control group, n = 16 (M age = 45.44, Intervention Group 2 showed improved
body,” refining the diet, fostering self-
25.0% male). sleep quality ( p < .001), ability to con-
awareness and self-control, and practicing
centrate ( p = .03), and gastrointestinal
Inclusion criteria: Outpatients at psychi- Shaolin mind–body exercises led by a clini-
health ( p = .02).
atric center in Hong Kong, aged 28–62, cal psychologist; 10 weekly 90-min sessions
diagnosis of MDD
Control
No psychological intervention
Chen et al. (2009) Level I Intervention • BAI No significant differences between

PMRT in a soundproof therapy room, • SAPS groups were found in change in SAPS
RCT repeated measures 1×/day at a set time each morning for • Finger temperature scores at the end of the intervention and
N = 18. 11 consecutive days follow-up.
Intervention group, n = 9 (M age = Control Anxiety severity was lower in the inter-
39.1, 50% male). No intervention vention group than in the control group
after 11 days of intervention ( p < .0001)
Control group, n = 9 (M age = 41.0, and at 1-wk follow-up ( p = .0446).
13% male).
Finger temperature increased signifi-
Inclusion criteria: DSM–IV diagnosis cantly in the intervention group after 11
of schizophrenia, BAI score >7 before days of PMRT ( p < .05).
recruitment, no history of drug abuse or
organic brain disease, currently receiving
inpatient treatment in acute psychiatric
ward, willing to accept treatment with
limited number of atypical antipsychotics
(Continued)
A78

Cramer et al. (2013) Level I Intervention • BPRS Moderate evidence was found for
Yoga intervention including ≥1 of the • PANSS short-term improvements in QOL after
Systematic review following: physical activity, breath con- • CGI participation in yoga for people with
N = 5 studies. trol meditation, lifestyle advice • WHOQOL–BREF schizophrenia ( p = .02).
Inclusion criteria: RCTs and randomized Control Limited evidence was found for symp-
crossover studies with participants with Exercise or other active nonpharmaco- tom relief, and no evidence was found
schizophrenia logical intervention for improved function.
Ikai et al. (2013) Level I Intervention Center of pressure postural sway At 8 wk, the intervention group showed
Yoga sessions led by a yoga instructor, significant improvements in the domains
RCT single blind 1 hr weekly for 8 wk, then regular day of total length of trunk motion ( p = .008)
N = 49. care until 16-wk follow-up and Romberg ratio ( p = .009).
Intervention group, n = 25 (M age = Control At 16 wk, the intervention group

54.8, 64% male). Weekly regular day care program showed significant improvements in
total length of trunk motion ( p = .002)
Control group, n = 24 (M age = 51.5 yr, and Romberg ratio ( p = .023).
66.7% male).
Inclusion criteria: Outpatients aged ≥18

yr, diagnosis of schizophrenia or related
psychotic disorder, had received same
medications for previous 8 wk, regis-
tered in hospital’s day care center
Ikai et al. (2014) Level I Intervention Resilience Scale Neither group showed significant
Yoga sessions led by a yoga instructor, improvements at 8 and 16 wk.
RCT single blind 1 hr weekly for 8 wk, then regular day
N = 50. care until 16-wk follow-up
Intervention group, n = 25 (M age = Control

53.5, 64% male). Weekly regular day care program

68% male).
Inclusion criteria: Outpatients aged ≥18,

diagnosis of schizophrenia or related
psychotic disorder, had received same
medications for previous 8 wk, regis-
tered in hospital’s day care center
A79
(Continued)

Ly et al. (2014) Level I Intervention • BDI–II No significant differences between

8-wk smartphone-based behavioral • PHQ–9 groups were found on the outcome
RCT activation intervention consisting of measures.
N = 81. web-based psychoeducation and step-
by-step behavior program with minimal Intervention participants classified as
Intervention group, n = 40 (M age = therapist contact, max. 20 min/wk having high-severity depression showed
36.6, 30% male). improvements in PHQ–9 scores ( p < .05).
Control
Control group, n = 41 (M age = 35.6, 8-wk smartphone-based mindfulness Control group participants classified as
29.3% male). intervention having low-severity depression showed
improvements in BDI–II ( p < .01) and
Inclusion criteria: Aged ≥18, point total of PHQ–9 ( p < .05) scores.
≥5 on PHQ–9, diagnosis of major depres-
sion, unchanged medication dosage for
depression and anxiety during past month,
not receiving psychological treatment at
time of study, no comorbid psychiatric con-
dition or other primary medical condition
that might interfere with treatment, no
severe alcohol problems, no risk of suicide
Sarubin et al. (2014) Level I Intervention • HAM–D21 No significant differences were found
Hatha yoga therapy, 60 min/wk, plus • HPA axis activity between groups in HAM–D21 scores
RCT pharmacological treatment of quetiap- ( p = .862) or HPA axis activity ( p = .054).
N = 53. ine fumarate extended (300 mg/day) or
escitalopram (10 mg/day) over 5 wk
37.27, 64.0% male). Control
Pharmacological treatment of quetiap-
Control group, n = 31 (M age = 42.37, ine fumarate extended (300 mg/day) or
87.4% male). escitalopram (10 mg/day) with no yoga
Inclusion criteria: Aged 18–65, major
depressive episode
Vancampfort et al. Level I Intervention • Mean change in psychological dis- Some evidence was found that progres-
(2013) Progressive muscle relaxation tress and anxiety scores sive muscle relaxation can reduce state
Systematic review • Mean change in positive and nega- anxiety and psychological distress and
Control tive symptoms improve subjective well-being.
N = 3 studies. Minimal treatment, psychological treat-
Inclusion criteria: RCTs examining pro- ment, or lifestyle or complementary
gressive muscle relaxation within mul- treatment
tidisciplinary management of patients

with schizophrenia
A80
(Continued)

Vancampfort, Level I Intervention • SAI The intervention group showed improve-

De Hert, Knapen, Progressive muscle relaxation consisting • SEES ments in SAI and SEES scores ( p < .001).
Maurissen, et al. (2011) RCT of testing and relaxing five major muscle • P ECC
N = 64. groups in a 25-min single session led by
a trained physiotherapist
35.74, 67% male). Control
No intervention
Control group, n = 32 (M age = 35.40
yr, 52% male).
Inclusion criteria: Acute care inpatient,

DSM–IV diagnosis of schizophrenia
Vancampfort, Level I Intervention • SAI Anxiety scores improved with yoga

De Hert, Knapen, Single 30-min yoga session, single • SEES ( p < .0001) and exercise ( p < .0001).
Wampers, et al. (2011) RCT crossover 20-min aerobic exercise session
Psychological stress scores improved with
N = 57. Control yoga ( p < .0001) and exercise ( p < .001).
Inclusion criteria: Diagnosis of schizo- Single 20-min session of no exercise
Subjective well-being scores improved
phrenia or schizoaffective disorder, CGI–S with yoga ( p < .0001) and exercise
score ≥4 assessed by a trained psychiatrist, ( p < .0001).
cooperative for yoga and aerobic exercise
Vancampfort, Level I Intervention • Mean change in general Support was found for the effectiveness
Vansteelandt, Yoga psychopathology of yoga in reducing general psychopa-
et al. (2012) Systematic review • Mean change in positive and nega- thology and positive and negative symp-
Control tive symptoms toms and improving HRQOL.
N = 3 studies. Any control type (e.g., wait list, add-on) • Mean change in HRQOL
Inclusion criteria: Studies examining
yoga as an intervention for patients with
schizophrenia
Varambally et al. (2013) Level I Intervention • BAS The intervention group showed signifi-
Yoga sessions taught by a yoga instruc- • WHOQOL–BREF cant improvement in scores on the BAS
RCT pilot study tor, 3×/wk for 4 wk, with continuing • HADS ( p = .018), WHOQOL–BREF ( p = .027),
N = 29. practice at home until 3-mo follow-up and HADS Psychological Well-Being
domain ( p = .034). The control group
Intervention group, n = 15. Control showed no significant improvement on
No intervention any outcome measure.
Inclusion criteria: Caregivers aged

18–60 yr of outpatients diagnosed with
schizophrenia, schizoaffective disorder,
A81
or bipolar disorder with psychosis
(Continued)

Visceglia & Lewis (2011) Level I Intervention • PANSS The intervention group showed signifi-
Conventional psychiatric treatment plus • WHOQOL–BREF cant improvements in all subscale scores
RCT pilot study group yoga therapy, 45-min sessions of PANSS ( p < .001) except Thought
N = 18 (33.7% male). 2×/wk for 8 wk Disturbance and on the Physical Health
( p < .04) and Psychological ( p < .01)
Intervention group, n = 10 (M age = 37.40). Control subscales of the WHOQOL–BREF.
Wait list, conventional psychiatric
Control group, n = 8 (M age = 48.13). treatment The control group did not show any
significant improvements in PANSS or
Inclusion criteria: Long-stay unit patients
WHOQOL–BREF scores.
with schizophrenia, projected or current
stay of >3 mo cleared by medical director
Yeung et al. (2012) Level I Intervention • HAM–D17 No significant differences were found
Group tai chi classes following a stan- • CGI–S between groups on any outcome
RCT pilot study dard protocol, 1 hr 2×/wk for 12 wk; • CGI–I measure.
N = 39. participants encouraged to practice at • Q–LES–Q–SF
home 3×/wk and keep a practice log • MSPSS
54, 23.1% male). Control
Wait list, no intervention
11.6% male).
Inclusion criteria: Aged 18–70, diagnosis

of MDD, baseline score of ≥12 on the
HAM–D17, self-identify as Chinese eth-
nicity, fluent in Mandarin or Cantonese
Exercise
Acil et al. (2008) Level I Intervention • SAPS The intervention group showed signifi-
Aerobic exercise program, 40-min ses- • SANS cant improvements in SAPS, SANS, and
RCT sions 3×/wk for 10 wk; 25-min sessions • BSI BSI scores, whereas the control group
N = 30. for first 2 wk to condition participants • WHOQOL–BREF Turkish version did not.
Intervention group, n = 15. Control On the WHOQOL–BREF Physical and

No intervention Mental domains, the intervention group
Control group, n = 15. showed significant improvements. No
significant differences were found in
Inclusion criteria: DSM–IV diagnosis of
the Social, Environmental, or Cultural
schizophrenia, discharged from previous

domains. No significant differences were
hospitalization, followed up as outpa-
found for the control group.
tients 1992–2005, used antipsychotics
A82
during 10-wk program
(Continued)

Battaglia et al. (2013) Level I Intervention • Weight The intervention group showed a sig-
Soccer training sessions, 2×/wk for • BMI nificant improvement in 30-m sprint
RCT 12 wk • Self-reported health QOL (SF–12) test time and a significant decrease in
N = 18. • 30-m sprint test and slalom test run- weight and BMI compared with the
Control ning with a ball control group.
Intervention group, n = 9. No regular sports activity during experi-
mental period
Inclusion criteria: Men aged ≥18, diag-

nosis of schizophrenia or schizoaffective
disorder, no comorbid disorder, moti-
vation to play soccer, able to provide
informed consent, stable antipsychotic
program, able to participate in physical
activity as attested by medical certificate
and psychiatrist’s consent, ≥1 yr of soc-
cer experience and basic level of techni-
cal and tactical skills, able to attend
≥80% of training sessions
Beebe et al. (2010) Level I Intervention • Self-Efficacy for Exercise Scale After the interventions, mean scores on
Walk, Address Sensations, Learn About • OEES the Self-Efficacy for Exercise Scale were
RCT Exercise, Cue Exercise intervention, 4 significantly higher for the intervention
N = 97 (M age = 46.9, 54% male, 43% weekly 1-hr group sessions group, but mean OEES scores were sig-
African-American). nificantly higher for the control group.
Control
Intervention group, n = 48. Time and attention control, 4 weekly
1-hr group sessions
Inclusion criteria: Chart DSM–IV diag-

nosis of schizoaffective disorder, schizo-
phrenia, or schizophreniform disorder;
English speaking; clearance for moder-
ate exercise in writing from primary care
provider
(Continued)
A83

Beebe et al. (2013) Level I Intervention Steps (pedometer) No significant difference was found
Walking program, 1 hr weekly for 4 wk between groups in number of daily steps
(follow-up to RCT ( p = .14).
Beebe et al., 2010) Control
N = 22 (age range = 23–71, 50% No intervention
male).

phrenia or schizoaffective disorder,
English speaking, stable medication
program, clearance from primary care
physician for moderate physical activity
Belvederi et al. (2015) Level I Intervention Primary More intervention participants (both
Group 1: Higher-intensity, progressive • HDRS groups) than control participants
RCT aerobic exercise (mainly using exercise reached remission ( p = .001).
bicycles), 60-min supervised group ses- Secondary
N = 121. • HDRS No significant between-group differ-
sions 3×/wk for 24 wk, plus sertraline
Intervention Group 1, n = 42. • CGI ences in change in depressive symptoms
Group 2: Lower-intensity, nonprogres- • Aerobic capacity or aerobic capacity were found.
Intervention Group 2, n = 37. sive exercise (mainly mat work and
instrumental exercises), 60-min super-
vised group sessions 3×/wk for 24 wk,
Inclusion criteria: Aged 65–85, plus sertraline
diagnosis of depression, capable of
Control
physical exercise, HAM–D21 score ≥18,
Sertraline only
sedentary
Chalder et al. (2012) Level I Intervention Primary No significant differences were found
Physical activity group intervention to • BDI between groups.
RCT promote participation in activities of
all intensity delivered in 3 face-to-face Secondary
N = 361. • Depressive symptoms
and 10 telephone contacts by a trained
Intervention group, n = 182. physical activity facilitator over 8 mo • QOL
• Antidepressant use
Control group, n = 179. Control • Physical activity
TAU
Inclusion criteria: Aged 18–69, diagno-

sis of depression, BDI score >14, not
currently taking antidepressant
A84
(Continued)

Danielsson et al. (2014) Level I Intervention Primary Intervention Group 1 improved signifi-
Group 1: Person-centered aerobic exer- • MADRS cantly more than Group 2 in MADRS
RCT cise group for 10 wk scores (p = .048).
Secondary
N = 62 (age range = 18–65). Group 2: Person-centered basic body • GAF Intervention Group 1 improved signifi-
Intervention Group 1, n = 22 (6 men). awareness therapy for 10 wk • Self-reported depressive symptoms cantly more than both Group 2 and the
• BAI control group in self-reported depressive
Intervention Group 2, n = 20 (4 men). Control • Scale of Body Connection symptoms and cardiovascular fitness.
1 individual session with a physical ther- • VO max
2
Control group, n = 20 (4 men). apist to receive advice and motivational
support for physical activity
Inclusion criteria: Aged 18–65, diagno-
sis of major depression
Esquivel et al. (2008) Level I Intervention • Panic Systems List The intervention group showed signifi-
Moderate to difficult group exercise • Visual Analogue Scale for Anxiety cant improvements in both outcome
RCT on a bicycle ergometer (100 W for measures compared with the control
N = 18. women, 150 W for men) at 80%–90% group.
of maximal heart rate for 15 min or until
Intervention group, n = 10 (M age = 30.1). exhaustion
Control group, n = 8 (M age = 29.1). Control

Very light exercise on a bicycle ergom-
Inclusion criteria: Outpatients with panic
eter at 1 W/kg of body weight
disorder diagnosis in Mexico City, no
serious or severe medical condition
Farholm & Sørensen Level I Intervention • Self-efficacy for exercise In the 1 study on increasing motivation for
(2016) Weekly 1-hr sessions based on social • Steps (pedometer) physical activity, the intervention group
Systematic review cognitive theory, 16-wk walking pro- • Self-efficacy for not slowing down showed significantly higher self-efficacy
N = 13 studies. gram, and varying intensity training pro- during work intervals and lower outcome expectation compared
grams in martial arts, bicycling, running, • Confidence in exercise with the control group. However, a follow-
Inclusion criteria: Peer-reviewed jour- or physio training • Confidence to change eating and on study found no Group × Time interac-
nal article; quantitative study design; activity to control weight tion effect for any of the outcome variables.
intervention involving physical activity
or exercise or education on physical In the 9 interventions in which motiva-
activity or exercise incorporating motivation was a secondary outcome, signifi-
tional constructs, theory, or techniques; cant increases in self-efficacy were found
participants with generic diagnosis of for a jogging and a martial arts interven-
psychosis or serious mental disorder tion, but no significant differences were
or specific diagnosis of schizophrenia, found for other interventions such as
bipolar disorder, or MDD climbing, walking, or stationary bicycling,
and no Group × Time interaction was
found for interventions to promote exer-
cise self-efficacy or confidence to change
A85
eating and activity to control weight.
(Continued)

Firth et al. (2015) Level I Intervention • Weight In 10 of 11 trials looking at physical

Exercise, including yoga, aerobic interval • BMI health, exercise resulted in significant
Systematic review training, soccer training, or strength • Physical health differences in body weight or BMI.
N = 17 studies. training • Mental health
• Metabolic health 2 studies found a significant reduction
N = 659 participants (Mdn age = 33, • Physical fitness in body weight from group training
range = 25–52). • Psychiatric symptoms programs.
• QOL 3 studies reported clinically significant
Inclusion criteria: Peer-reviewed articles
• Neurocognitive effects increases in VO2 max.
in English, published 1994 or later,
• VO2 max
examined effect of exercise on ≥1 quan- Two RCTs that used 120 min/wk of
• Depression
titative measure of physical or mental moderate to vigorous exercise reported
• Hippocampal volume
health, examined physical or mental significant improvements in QOL.
effects of exercise interventions in par-
ticipants with nonaffective psychotic 3 trials using specific measures of
disorders depression reported that 120 min/wk
of aerobic–resistance exercise reduced
depression significantly more than an
occupational therapy control condition.
1 study observed a significant main

effect of exercise on hippocampal vol-
ume, which increased by 12%.
Greer et al. (2015) Level I Intervention Attention The intervention group made sig-
High-dose aerobic exercise (12 KKW for • Big/little circle nificantly fewer errors based on spatial
RCT 12 wk) • Reaction time working memory than the control group.
N = 39. Control Visual memory No significant differences between
Intervention group, n = 19 (M age = Low-dose aerobic exercise (4 KKW for • Delayed matching to sample groups were found on the other out-
45.4, 10.5% male). 12 wk) • Paired associates learning come measures.
• Pattern
15.0% male). EF
• Intra/extra
Inclusion criteria: Aged 18–65, diagno- • Spatial working memory
sis of MDD, treated with SSRI for 8–12 • Stockings of Cambridge
wk with incomplete response, sedentary
(Continued)
A86

Hoffman et al. (2011) Level I Intervention • HDRS No comparisons were made between
Group 1: Supervised group aerobic exer- • MDD status groups.
RCT cise supervised by exercise physiologists, • G odin Leisure-Time Exercise
45-min sessions 3×/wk Questionnaire Improvements were seen in Godin ques-
N = 172. tionnaire scores across all groups.
• Perceived Social Support Scale
Intervention Group 1, n = 43. Group 2: Home-based aerobic exercise
program after initial training session
Intervention Group 2, n = 48. with an exercise physiologist
Intervention Group 3, n = 41. Group 3: Sertraline
Placebo pill
Inclusion criteria: None reported
Holley et al. (2011) Level I Intervention • Quality of Life Scale 2 high-quality studies found significant
Aerobic or anaerobic exercise or physical • Nurses’ Observation Scale for improvement in mental health and gen-
Systematic review activity Inpatient Evaluation eral psychological well-being.
N = 12 studies (6 preexperimental, 5 • MHI
• Profile of Mood States 2 high-quality studies reported a signifi-
quasi-experimental, 1 RCT). cant overall increase in social competence.
• STAI
N = 356 participants (63.8% male). • Physical Self-Efficacy Scale 1 study reported a significant increase
• Perceived Competence Scale in physical self-efficacy, 1 reported sig-
Inclusion criteria: Articles published in
• Level of Functioning and Optimal nificantly reduced anxiety levels, and 2
peer-reviewed journals 1978–2008; any
Performance Test found a significant reduction in irritability.
study design; participants aged ≥15 with
diagnosis of schizophrenia, schizoaffective One low-quality study found significant
disorder, or schizophreniform disorder; decreases in tension.
exercise or physical activity interventions
Jayakody et al. (2014) Level I Intervention • CGI Exercise combined with antidepressant
Structured running, clomipramine, • BAI medication improved CGI scores in 1
Systematic review placebo, aerobic exercise with parox- • EuroQol–5D RCT (p < .05).
N = 8 studies. etine, exercise with placebo, rest with • DASS–Anxiety
paroxetine, rest with placebo, various • STAI Exercise combined with occupational
Inclusion criteria: RCTs of exercise inter- intensities of exercise, aerobic and • Comprehensive Psychopathological therapy and lifestyle changes reduced
ventions for anxiety disorders, identified nonaerobic exercise, exercise with CBT, Rating Scale BAI scores in 1 RCT (p =.0002).
in 6 online databases group classes with CBT, group exercise For social phobias, added benefits of
programs exercise were shown when combined
Control: NA with group CBT (p < .05).
No significant difference was found

between aerobic and anaerobic exercise
groups in 1 RCT (p > .1), and partici-
pants in both groups showed reduced
A87
anxiety symptoms in 1 RCT (p < .001).
(Continued)

Kerling et al. (2015) Level I Intervention • MADRS No significant differences between

Aerobic exercise at moderate intensity • BDI–II groups were found in MADRS or BDI–II
RCT (50% of maximum workload), 45-min • Effects on metabolic syndrome scores or metabolic syndrome measures.
N = 42. sessions 3×/wk for 6 wk • Exercise capacity
Intervention group, n = 22 (M age = Control cant improvement in exercise capacity
44.2, 55% male). TAU compared with the control group.

70% male).
Inclusion criteria: Inpatients with diag-
nosis of MDD in Germany
Kerse et al. (2010) Level I Intervention Primary No significant difference was found
Activity group intervention based on • Short Physical Performance Battery between groups on any of the outcome
RCT the Otago Exercise Program consisting • Nottingham Extended Activities of measures.
N = 193. of moderate-intensity balance retrain- Daily Living
ing, progressive resistance lower limb
Intervention group, n = 97 (M age = strengthening exercises, and walking Secondary
81.4, 38% male). • SF–36 Mental Component Summary
Control • GDS–15
Control group, n = 96 (M age = 80.8, Active social contact • Auckland Heart Study Physical
49% male). Activity Questionnaire
• Abbreviated Mental Test Score
Inclusion criteria: Aged ≥75, community
• Composite International Diagnostic
dwelling, English speaking, diagnosis of
Interview
depression
Krogh et al. (2012) Level I Intervention Primary No significant differences were found
Aerobic exercise group in which partici- • HAM–D between groups in HAM–D or BDI
RCT pants carried a pulse monitor to mea- • BDI scores or on any secondary measure.
N = 115 (M age = 41.6, 33% male). sure VO2 max during exercise, 3×/wk for
3 mo (36 sessions) Secondary
Intervention group, n = 56. • WHO-5 Well-Being Index
Control • Danish Adult Reading Test
Control group, n = 59. Low-intensity stretching group (atten- • Buschke Selective Reminding Test
tional control), 3×/wk for 3 mo (36 • Rey’s Complex Figure Test
Inclusion criteria: Aged 18–60, referred
sessions) • Trails A and B
from a clinical setting, diagnosis of
• Verbal Fluency S and Animals
major depression, HAM–D17 score >12
• Weight
• Blood pressure
A88
(Continued)

Lee et al. (2014) Level I Intervention • IPAQ short form No significant differences between
Pedometer and 8 weekly phone calls; no • BMI groups were found in clinical outcomes
RCT active exercise • W aist circumference (e.g., BMI, waist circumference).
N = 16 (M age = 44.09, 54.5% male). • Blood pressure
Control • Fasting glucose and lipid profiles Walking minutes measured using the
Intervention group, n = 8. Written information about physical IPAQ increased significantly for the exer-
activity cise group compared with the control
Control group, n = 8. group.
Inclusion criteria: Aged 18–60, diagnosis of
schizophrenia spectrum disorder, receiving
psychotropic medication, clearance from a
physician to do moderate physical activity
Loh et al. (2016) Level I Intervention Primary The intervention group showed sig-
Structured walking group intervention, • QOL (SF–36) nificant improvements in SF–36 scores
RCT 3 sessions per week for 3 mo, with ses- compared with the control group.
sions lasting 20 min for 1st mo, 30 min Secondary
N = 104 (M age = 21.6, 71.2% male, • PANSS The intervention group also showed sig-
61.5% Malay). for 2nd mo, and 40 min for 3rd mo
• PSP nificant improvement on both secondary
Intervention group, n = 52. Control outcome measures, whereas the control
Usual schizophrenia group treatment group did not.
Inclusion criteria: Inpatients in Malaysia,
aged 18–65, diagnosis of schizophrenia
Marzolini et al. (2009) Level I Intervention • 6-min walk test The exercise group showed improvements
Group exercise sessions 2×/wk at a • 1RM on bicep curl on the 6-min walk test, strength (p = .01),
RCT community recreation center plus an • Anthropometric measures and the MHI (p = .03), whereas the control
N = 13. extra aerobic exercise session 1×/wk on • Attendance group showed a decrease in the 6-min
their own, over 12 wk • 18-item MHI walk test and no significant improvement
Intervention group, n = 7 (4 male). • Feedback survey in strength (p = .2) or on the MHI (p = .57).
Control
Control group, n = 6 (4 male). TAU No significant differences were found
between groups (p = .1).
Inclusion criteria: DSM diagnosis of
schizophrenia or schizoaffective disor- Completion of home-based exercise
der, ≥1 cardiovascular risk factor sessions was significantly lower than
completion of group-based exercise ses-
sions (p < .001).
On the feedback survey, participants

indicated mean ratings of 4.3 on a scale
A89
of 1 (poor) to 5 (excellent).
(Continued)

Merom et al. (2008) Level I Intervention • DASS The intervention group had greater
30-min sessions of brisk walking or • Active Australia Questionnaire declines in depression score (p = .001),
RCT other exercise delivered and monitored anxiety score (p = .002), and stress
N = 74. by an exercise trainer, with a goal of ≥5 score (p = .02) than the control group.
sessions per week for ≥150 min total
Intervention group, 38 (29% male).
Control
Control group, 36 (14% male). 3 educational meetings with a focus on
healthy eating
Inclusion criteria: DSM–IV diagnosis
of generalized anxiety disorder, panic
disorder, or social phobia; able to par-
ticipate in group CBT
Pajonk et al. (2010) Level I Intervention • Cognitive testing Relative hippocampal volume increased
Exercise group: 30-min aerobic training • Magnetic resonance imaging by approximately 14% in the interven-
RCT sessions for participants with schizo- acquisition tion group (p = .001).
N = 24. phrenia, 3×/wk for 12 wk; participants • Structural image analysis
had to attend ≥75% of sessions • Magnetic resonance spectroscopy The intervention group had a 35%
Exercise group, n = 8. acquisition increase in the N-acetylaspartate to
Nonexercise group: 30-min sessions of creatine ratio (p = .04), whereas the ratio
Nonexercise group, n = 8. tabletop football for participants with schizo- of the control group decreased 16%.
phrenia in an environment that provided
Control group, n = 8. The intervention group had a 34%
stimulation comparable to that provided for
the exercise group, 3×/wk for 12 wk increase in short-term memory score,
Inclusion criteria: DSM–IV or ICD–10
whereas the control group had a 17%
diagnosis of schizophrenia; control par-
Control decrease, changes associated with
ticipants were healthy individuals with
30-min aerobic training sessions for changes in hippocampal volume
similar demographics as the exercise
healthy participants, 3×/wk for 12 wk (p < .05).
group
Pearsall et al. (2014) Level I Intervention • 6-min walk test Exercise did not lead to significant
Various forms of exercise, such as • BMI changes in symptoms of mental health,
Systematic review cycling or muscle strengthening • No. of exercise sessions attended BMI, or body weight.
N = 8 studies. • Minutes walked
Inclusion criteria: RCTs; adult partici-

pants of all ages, ethnicities, and sexes
with schizophrenia or other type of
schizophrenia-like psychosis, schizoaf-
fective disorders, or bipolar affective dis-

order in the community or the hospital;
interventions with a primary or second-
A90
ary goal to promote physical activity
(Continued)

Pfaff et al. (2014) Level I Intervention • MADRS structured interview guide Both groups displayed similar remission
12-wk home-based program to promote • Structured Clinical Interview for of depressive illness.
RCT physical activity at a level that met DSM–IV Axis I Disorders
N = 200. published exercise guidelines for people
aged ≥65 yr plus usual medical care
Control
Control group, n = 92. Usual medical care
Inclusion criteria: Aged ≥50, diagnosis
of depressive illness, under care of a
general practitioner
Rethorst et al. Level I Intervention 4 sleep items from 30-item IDS– The intervention group showed signifi-
(2013) High dose of aerobic activity (16 KKW) Clinician: sleep onset insomnia, cant improvement (decrease) in total
RCT plus SSRI for 12 wk midnocturnal insomnia, early morning insomnia (p < .0001) and in sleep onset
N = 122. insomnia, hypersomnia insomnia, midnocturnal insomnia, and
Control early morning insomnia (p < .002). No
Intervention group, n = 61 (M age = Low dose of aerobic activity (4 KKW) significant change was found in hyper-
45.6, 14.8% male). plus SSRI for 12 wk somnia (p = .38).
Control group, n = 61 (M age = 48.5 yr, No significant difference between
21.3% male). groups was found in total insomnia or in
any individual sleep item.
Inclusion criteria: Outpatients aged
18–70 yr, diagnosis of nonremitted MDD
Rosenbaum et al. Level I Intervention • HDRS Physical activity resulted in decreased

(2014) Exercise programs, exercise counseling, • GDS depressive symptoms in people with a
Systematic review lifestyle interventions, tai chi, physical • BDI psychiatric illness and reduced symp-
N = 39 RCTs. yoga • DASS toms of schizophrenia.
Inclusion criteria: RCTs; adult partici-

pants aged >18 yr; DSM, ICD, or other
diagnosis of mental illness
(Continued)
A91

Scheewe et al. (2013) Level I Intervention • PANSS Exercise therapy had a significant effect
Structured aerobic exercise, 1 hr 2×/wk • Cardiopulmonary exercise test on cardiovascular fitness (p < .01) com-
RCT for 6 mo • MADRS pared with occupational therapy.
N = 63. • Camberwell Assessment of Needs
Control • BMI Exercise therapy reduced symptoms of
Intervention group, n = 31. Occupational therapy, 1 hr 2×/wk for • Body fat percentage schizophrenia (p = .001) and depression
6 mo • Metabolic syndrome (p = .012) and need for care (p = .05)
Control group, n = 32. and increased cardiovascular fitness
(p < .001) compared with occupational
Inclusion criteria: DSM–IV diagnosis of
therapy.
schizophrenia, schizoaffective disorder,
or schizophreniform disorder; stable on
antipsychotic medication
Schuch et al. (2011) Level I Intervention • HAM–D17 Both groups achieved a reduction in
Aerobic exercise during hospital stay, • Ebbeling Submaximal Test depressive symptoms at 2 wk (p < .001)
RCT 3 sessions per week, plus conventional • WHOQOL–BREF and at discharge (p < .001).
N = 26. treatments including pharmacological
and/or electroconvulsive therapy At discharge, a between-group differ-
Intervention group, n = 15 (M age = ence favored the intervention group
42.8). Control (p = .041).
Conventional treatments including phar-
Control group, n = 11 (M age = 42.5). macological and/or electroconvulsive Both groups showed improvements in
therapy QOL, but the intervention group had
Inclusion criteria: Aged 18–60; significantly favorable differences at
DSM–IV diagnosis of MDD; HAM– discharge (p = .004).
D17 score ≥25; not involved in other
physical activity program during
hospitalization; able to read, under-
stand, and provide written informed
consent
Silva et al. (2015) Level I Intervention • PANSS In both intervention groups, disease
Group 1: Resistance training exercises • Medication monitoring symptoms improved after 10 wk
RCT focused on large muscle groups impor- • Calgary Depression Scale for (p = .026) and 20 wk (Group 1,
N = 34. tant for ADLs, including leg press, leg Schizophrenia p = .001; Group 2, p = .003), whereas
curl, vertical traction, chest press, arm • SF–36 symptoms remained stable in the control
extension, arm curl, and abdominal • Biomarker measurements group.
crunch, 60 min 2×/wk for 20 wk • Weight
• BMI
(Continued)
A92

Intervention Group 1, n = 12. Group 2: Resistance training exercises • Height In Intervention Group 1, positive symp-
matching Intervention Group 1 with dif- • 1RM test toms improved at 10 wk (p = .039) and
Intervention Group 2, n = 9. ferent training volume plus aerobic pro- • Progressive load test 20 wk (p = .001), whereas in Group 2,
Control group, n = 13. gram consisting of walking and running • VO2 max positive symptoms improved only at 20
on a treadmill, 60 min 2×/wk for 20 wk wk (p = .016); no change was found for
Inclusion criteria: Men aged 18–50 the control group.
referred by two clinics in Brazil, DSM–IV Control
diagnosis of schizophrenia, clinically Same protocol as intervention groups
stable disease, stable dosage of medica- with equipment load kept at the mini-
tion for ≥6 wk, sedentary lifestyle >1 yr, mum and treadmill speed at 4 km/hr, 60
clinical evaluation by a laboratory min 2×/wk for 20 wk
physician
Silveira et al. (2013) Level I Intervention Depression symptoms The meta-analysis found a significant
Some form of exercise, including aerobic difference between aerobic training and
Systematic review and meta-analysis training or strength training control groups (p = .001) and between
N = 10 studies. strength training and control groups
(p = .06).
Inclusion criteria: Longitudinal studies,
clinical trials, and RCTs; participants When the analysis was conducted only
with depression; physical exercise as a with studies that used the HDRS, a
single treatment for the group or com- reduction of 3.49 points was observed
bined with pharmacological treatment in the intervention groups compared
with the control groups.
Remission was 14% higher in the

intervention groups but did not reach
significance.
Stubbs et al. (2016) Level I Intervention VO2 max Exercise interventions resulted in signifi-
Some form of exercise intervention cant improvement in cardiorespiratory
Systematic review consisting of physical activity that was fitness (p < .001).
N = 35 studies. planned, structured, repetitive, and pur-
posive to maintain or improve physical
fitness or health
(Continued)
A93

Inclusion criteria: Studies that included

adult participants with a primary diag-
nosis of MDD according to the DSM–IV
or American Psychiatric Association or
individuals with depressive symptoms
above standard thresholds according to
a validated screening measure, exercise
interventions, measure of cardiorespira-
tory fitness expressed as predicted maxi-
mal oxygen uptake
Trivedi et al. (2011) Level I Intervention • IDS Both groups showed significant
Higher-end public health dose of walk- • HDRS improvements (p < .0001).
RCT ing with total energy expenditure of 16 • Quick IDS
KKW, which required participants to • SF–36 Men, regardless of family history of
N = 122. mental illness, and women without
walk at about 4 mph for 210 min/wk • Social Adjustment Scale
Intervention group, n = 61. for 12 wk • Q–LES–Q–SF a family history of mental illness had
higher remission rates at 12 wk with
Control group, n = 61. Control higher-dose than with lower-dose exer-
Lower-end public health dose of walking cise (women, p = .04; men, p < .0001).
Inclusion criteria: Aged 18–70,
with total energy expenditure of 4 KKW,
DSM–IV diagnosis of nonpsychotic
which required participants to walk at 3
MDD, completed 2–6 mo of SSRI treat-
mph for 75 min/wk for 12 wk
ment, reported improvement from SSRI
monotherapy with at least moderate
residual depressive symptomatology,
not engaged in regular exercise, able to
engage in exercise
Vancampfort, Probst, Level I Intervention • Mental health The evidence indicates that aerobic and
et al. (2012) Physical therapy interventions includ- • Physical health strength exercises along with progres-
Systematic review ing aerobic exercises, strength exer- • HRQOL sive muscle relaxation can improve
N = 10 RCTs. cises, relaxation training, and basic mental health outcomes such as mental
body awareness exercises, alone or in state, state anxiety, and psychological
Inclusion criteria: Studies of people diag- combination distress.
nosed with schizophrenia
(Continued)
A94

Wedekind et al. (2010) Level I Intervention • Panic and Agoraphobia Scale On the Panic and Agoraphobia Scale,
Group 1: Aerobic exercise (running or • CGI when paroxetine-treated participants
RCT walking) plus 40 mg/day of paroxetine • Hamilton Anxiety Rating Scale from both intervention groups were
N = 75. • Patient Global Impression Scale analyzed together, significantly better
Group 2: Relaxation plus 40 mg/day of improvement was found compared with
Intervention Group 1, n = 21. paroxetine placebo-treated participants (p < .05).
Intervention Group 2, n = 17. Control CGI scores showed a trend toward better
Group 1: Aerobic exercise plus placebo improvement in Control Group 1 com-
Control Group 1, n = 20.
Group 2: Relaxation plus placebo pared with Control Group 2 (p = .06).
Control Group 2, n = 17. When paroxetine-treated participants
from both intervention groups were
Inclusion criteria: Outpatients aged analyzed together, a significantly bet-
18–55 with panic disorder with or ter outcome was found compared with
without agoraphobia, Panic and placebo-treated participants (p < .05).
Agoraphobia Scale score ≥18, CGI score
of 4
Weight Loss
Attux et al. (2013) Level I Intervention • Weight No significant differences between

Standard care plus Lifestyle Wellness • BMI groups were found at the end of the
RCT Program consisting of discussion on intervention (3 mo; group interaction
N = 160. topics such as dietary choices, lifestyle, p = .093).
physical activity, and self-esteem, 1-hr
Intervention group, n = 81 (M age = weekly sessions After 6 mo, the intervention group
36.2, 38% male). demonstrated a decrease in weight
Control and the control group demonstrated an
Control group, n = 79 (M age = 38.3, Standard care in an outpatient program increase (p = .055), but the magnitude
28% male). of difference was small and not clinically
significant.
Inclusion criteria: Patients ages 18–65
enrolled in outpatient programs in The intervention group lost .99 lb at 3
Brazil, diagnosis on the schizophrenia mo and 3.74 lb at 6 mo.
spectrum, clinically stable, used any
antipsychotic in past 3 mo, motivated to
lose weight or have shown some con-
cern about weight gain
(Continued)
A95

Bartels et al. (2013) Level I Intervention Primary Significant differences in cardiorespira-

In SHAPE program consisting of ses- • Cardiorespiratory fitness (6-min walk tory fitness were found for the interven-
RCT sions with a fitness trainer, 45–60 min test) tion group compared with the control
N = 133. 1×/wk over 1 yr, plus a fitness club • Weight group (p = .020).
membership • BMI
Intervention group, n = 67 (M age = No differences between groups were
43.1, 28% male). Control Secondary found in mean weight change or BMI.
1 yr of fitness club membership and • IPAQ
Control group, n = 66 (M age = 44.4, education • Frequency of fitness club visits using The intervention group lost 1.8 lb at 3
23% male). sign-in log mo and gained 1.4 lb at 12 mo.
• Dietary behavior (self-report)
Inclusion criteria: Adults aged ≥21 from
a community mental health center in
New Hampshire April 2007–November
2008, SMI (Axis I disorder), persistent
impairment in multiple areas of func-
tioning, BMI >25, used same psychiatric
medications over previous 2 mo
Bartels et al. (2015) Level I Intervention Primary The intervention group demonstrated
In SHAPE program consisting of a fitness • Weight greater reduction in weight than the
RCT club membership and individual meet- • Cardiorespiratory fitness (6-min walk control group (p = .029).
N = 210. ings with a health promotion coach to test)
provide coaching in physical activity and The intervention group demonstrated
Intervention group, n = 104 (M age = instruction on healthy eating, 45–60 Secondary an increase in fitness, and the control
43.9, 49% male). min 1×/wk • BMI group demonstrated a decrease in fit-
• Waist circumference ness (p = .037).
Control group, n = 106 (M age = 43.5, Control • Minutes of exercise
45% male). Fitness club membership with introduc- • Physical activity score The intervention group lost 3.6 lb at 3
tory session on safe use of exercise mo and 5.3 lb at 12 mo.
Inclusion criteria: Patients from three
equipment
nonprofit community mental health pro-
viders in Boston area 2007–2011, aged
≥21, SMI (Axis I diagnosis), persistent
impairment in multiple areas of func-
tioning, BMI >25, used same psychiatric
medications over previous 2 mo
(Continued)
A96

Brown et al. (2014) Level I Intervention Weight A significant difference between groups
RENEW program for 1 yr, including was found at 3 mo (p = .01) but not at
RCT
3-mo intensive phase, 3-mo mainte- 6 mo (p = .22) or 12 mo (p = .47).
N = 92. nance phase, and 6-mo intermittent
support phase The intervention group lost 4.8 lb at 3
Intervention group, n = 47 (M age = mo and gained 1.5 lb at 12 mo.
44.4, 36% male). Control
TAU
30% male).
Inclusion criteria: Adults aged 18–65
from 2 urban and 1 suburban areas of
Kansas City and 1 urban area of Las
Vegas, confirmed diagnosis of SMI, BMI
≥25, medication stable
Bruins et al. (2014) Level I Intervention Primary Participants in Intervention 1 demon-

Intervention 1: Various lifestyle interven- • Weight change strated significant weight loss compared
Systematic review
tion programs aimed at weight loss with control groups, with a moderate
Secondary long-term effect (p = .02).
N = 25 RCTs.
Intervention 2: Various lifestyle interven- • Cardiometabolic risk factors
N = 1,518 participants. tion programs aimed at weight gain • Depressive symptoms Participants in Intervention 2 gained less
prevention body weight than control groups, with a
Intervention 1, n = 16 studies.
large long-term effect (p = .0002).
Control
Intervention 2, n = 8 studies.
Not reported
Inclusion criteria: RCTs in 4 databases
evaluating the effects of lifestyle interven-
tions on weight management in patients
with psychotic disorders until April 2014
Cordes et al. (2014) Level I Intervention Primary No significant differences between

Weight management program consist- • Weight groups were found after 24 wk.
RCT
ing of group psychoeducational training
sessions, 12 biweekly 90-min sessions Secondary The intervention group showed a smaller
N = 74.
• BMI increase in waist circumference than the
Intervention group, n = 36 (M age = Control • Waist circumference control group after 48 wk (p = .019).
38.2, 42% male). TAU
The intervention group showed a smaller
Control group, n = 38 (M age = 35.8, increase in fasting glucose (p = .031) and
71% male). 2-hr glucose (p = .018) after oral glucose
load than the control group.
Inclusion criteria: Inpatients in Germany
with schizophrenia or schizoaffective
disorder, being treated with olanzapine,
A97
gained ≥1.5 kg during first 4 wk after

initiation of treatment
(Continued)

Daumit et al. (2013) Level I Intervention • Weight The intervention group demonstrated
Weight loss intervention consisting of • BMI significant weight loss over 18 mo com-
RCT group weight management sessions, pared with the control group (p = .002).
N = 291 (M age = 45.3). individual weight management sessions,
and group exercise sessions The intervention group lost 3.96 lb at 6
Intervention group, n = 144 (M age = mo and 7.48 lb at 18 mo.
46.6, 48.6% male). Control
Standard nutrition and physical activity
Control group, n = 147 (M age = 44.1, information received at baseline, health
51.0% male). classes unrelated to weight offered
quarterly
Inclusion criteria: Overweight or obese
adults aged ≥18 who attended 1 of 10
community psychiatric rehabilitation
programs in central Maryland or their
affiliated outpatient mental health clinic
Forsberg et al. (2008) Level I Intervention • Weight No significant differences were found
Study circle with active participation • BMI between groups except in number of
RCT in learning, using a book with topics • Physiological measures metabolic criteria met, which decreased
N = 41. related to motivation, food content, • Satisfaction for the intervention group.
stress, and fitness, 2×/wk for 2 hr (1
Intervention group, n = 24 (M age = hr cooking, 1 hr physical activity) over Participants in both groups would rec-
39.8, 54% male). 12 mo ommend the study circle to a friend.
Control group, n = 17 (M age = 42.8, Control The intervention group lost 1.98 lb at
71% male). Aesthetic study circle meeting with 12 mo.
opportunities to learn and practice
Inclusion criteria: Residents in a sup-
artistic techniques, 2×/wk for 2 hr over
ported housing facility; diagnosis of
12 mo
schizophrenia, bipolar disorder, person-
ality disorder, other psychotic disorder,
or autism spectrum disorder; no or mild
cognitive impairment
(Continued)
A98

Goldberg, Reeves, Level I Intervention Primary No significant differences were found

et al. (2013) 6-mo trial of the MOVE! intervention • Weight between groups on any outcomes.
RCT with individual and group sessions • Metabolic syndrome
• Waist circumference The intervention group gained 3.6 lb at
N = 71. Control 6 mo.
• Dyslipidemia
Intervention group, n = 30 (M age = Basic information about diet and exer- • Blood pressure
50.5, 75% male). cise every month • High glucose
Control group, n = 41 (M age = 53.5, Secondary
86% male). • Physical activity
• Diet
• Attitude
phrenia, other psychotic spectrum disor-
• Impact of Weight on Quality of Life
der, bipolar disorder, major depression,
questionnaire
or severe anxiety disorder; aged 18–75,
• SF–12
community dwelling, BMI ≥25, English
speaking
Green et al. (2014) Level I Intervention • Weight loss The intervention group reported satis-
PREMIER program with DASH diet • Feasibility and acceptability faction with intervention content, struc-
RCT consisting of lifestyle interventions to ture, and group processes.
N = 36 (M age = 48.5, 19% male). encourage activity and a specific diet
The intervention group had significant
Intervention group, n = 18. Control weight loss compared to the control
TAU group.
The intervention group lost 6.7 lb at
Inclusion criteria: Overweight or obese 12 wk.
adults aged >18, BMI 25.0–44.9, had
been taking ≥1 antipsychotic medication
at any consistent dose for ≥30 days at
the time they were identified, could be
taking multiple antipsychotics
(Continued)
A99

Green, Janoff, et al. (2015) Level I Intervention • Weight Significant Time × Group effects were
STRIDE program consisting of moderate • BMI found for weight and BMI.
RCT caloric reduction, DASH diet, and physi- • Glucose metabolism
cal activity The intervention group lost more weight
N = 200. than the control group at 6 mo
Intervention group, n = 104 (M age = Control (p = .001) and 12 mo (p = .03).
46.2, 18% male). TAU
No significant difference in weight
Control group, n = 96 (M age = 48.3, change was found between groups dur-
18% male). ing maintenance (6–12 mo).
Inclusion criteria: Aged ≥18, had been The intervention group showed a
taking antipsychotic agents ≥30 days, greater decline in fasting glucose than
BMI ≥27 the control group at 6 mo (p = .02) and
12 mo (p = .01).
The intervention group lost 3.5 lb at 6
mo and 3.7 lb at 12 mo.
Iglesias-García et al. Level I Intervention • Weight No significant differences were found

(2010) Education program on nutrition, exercise • BMI between groups in BMI, weight, or
RCT and health habits, and self-esteem, 12 • Waist circumference waist circumference.
N = 15 (M age = 39.9, 68.8% male). sessions over 3 mo • Vital signs (blood pressure, pulse)
The intervention group lost 1.32 lb at 6
Intervention group, n = 8. Control wk but gained .02 lb at 12 wk.
Attendance at the clinic 1×/wk to assess
Control group, n = 7. anthropometric parameters
Inclusion criteria: Overweight and obese
outpatients with chronic stable schizo-
phrenia, taking antipsychotics
Krogh et al. (2014) Level I Intervention • Weight The 5 trials including participants with
Exercise interventions as a standalone or • BMI schizophrenia found little evidence that
Systematic review add-on treatment • C ardiovascular fitness exercise could increase cardiovascular
N = 14 studies (5 with schizophre- • Strength fitness or decrease weight.
Control
nia patients, 9 with patients with TAU The 9 trials including participants with
depression). depression found cardiovascular fitness
N = 950 participants. increased by 11%–30% and strength by
33%–37%.
Inclusion criteria: RCTs from PubMed,

Embase, and PsycINFO allocating patients No evidence in favor of exercise for
with either schizophrenia or depression weight reduction was found.
A100
to isolated exercise interventions
(Continued)

Masa-Font et al. (2015) Level I Intervention • Average weekly walking metabolic Average weekly walking metabolic
Education, physical activity program, equivalents equivalents increased significantly in the
RCT and diet • BMI intervention group at 3 mo (p = .036).
N = 332. • Waist circumference
Control BMI decreased significantly in the con-
Intervention group, n = 169 (M age = TAU consisting of regular checkups with trol group compared with the interven-
46.3, 55.0% male). psychiatrist and continued treatment as tion group (p = .038).
prescribed
Control group, n = 163 (M age = 47.1, No significant differences were found
54.6% male). between groups in waist circumference.
Inclusion criteria: Outpatients aged

18–65 from 10 public mental health
centers; diagnosis of schizophrenia,
schizoaffective disorder, or bipolar
disorder; treatment with antipsychotic
drug for ≥3 mo before enrollment; low
physical activity; BMI ≥25; resided in
residence ≥1 yr; knowledge of Spanish
Mauri et al. (2008) Level I Intervention • Weight During Wk 1–12, the intervention group
PEP for weight control based on a • Q–LES–Q–SF demonstrated significant weight loss com-
RCT dietary program, intensive 30-min • GAF pared with the control group (p < .01).
N = 33. weekly meetings over 24 wk • Plasma glucose
• Lipid levels During Wk 12–24, both groups (both
Intervention group, n = 15 (46.7% male). Control receiving PEP) demonstrated weight loss
No intervention and continued olanzap- (p < .01). No significant difference between
Control group, n = 18 (38.9% male). ine; started PEP at Wk 12 and continued groups was found at the final visit.
until Wk 24
Inclusion criteria: Psychiatric outpatients The intervention group lost 7.92 lb at
aged 18–65, BMI increase >7% during 12 wk and 9.9 lb at 24 wk.
treatment with olanzapine
Methapatara & Level I Intervention Primary A significant improvement in body

Srisurapanont (2011) Pedometer walking plus motivational • Weight weight in the intervention group was
RCT interviewing found only at 12 wk (p = .03).
Secondary
N = 64 (M age = 40.38, 64.06% male). Control • BMI A significant improvement in BMI was
Intervention group, n = 32 (M age = TAU with no pedometer • Waist circumference found in the intervention group at 12
43.16, 71.88% male). wk (p = .03).
Control group, n = 32 (M age = 37.59, Decreases in waist circumference were

56.25% male). significantly higher in the intervention
group at 4, 8, and 12 wk (p ≤ .01).
Inclusion criteria: Overweight or obese
A101
individuals in Thailand, diagnosis of The intervention group lost 1.76 lb at

schizophrenia, BMI ≥23 12 wk.
(Continued)

Pagoto et al. (2013) Level I Intervention • Weight loss No significant differences were found
Behavior therapy for depression fol- • BDI between groups in weight loss at 6 and
RCT lowed by a lifestyle intervention 12 mo.
N = 161 (M age = 45.9). Control The intervention group demonstrated
Intervention group, n = 78 (M age = Lifestyle intervention only significantly greater improvement in
45.6). depressive symptoms compared with
the control group at 6 and 12 mo (p =
Control group, n = 83 (M age = 46.2). .045).
Inclusion criteria: Obese women aged Participants who experienced depres-
21–65, BMI 30–40, diagnosis of MDD, sion remission by 6 mo lost more weight
recruited July 2007–March 2010 from than those who did not (p = .001).
community and primary care population
at University of Massachusetts Medical
School
Usher et al. (2013) Level I Intervention • Body measurements: girth, weight, No significant differences were found
Healthy lifestyle booklet and nutrition height, BMI between groups on any outcomes.
RCT education and exercise activity sessions, • Medication compliance questionnaire
weekly 1-hr sessions, plus nurse support • Drug Attitude Inventory The intervention group lost 1.63 lb at
N = 101 (53.5% male). 12 wk.
over 12 wk • Liverpool University Neuroleptic Side
Intervention group, n = 51. Effect Rating Scale
Control • SF–36
Control group, n = 50. Healthy lifestyle booklet
Inclusion criteria: SMI, aged ≥18, not
currently psychotic, prescribed and tak-
ing second-generation antipsychotic
medication, living in Australia, able to
speak and read English
(Continued)
A102

Wu et al. (2008) Level I Intervention • BMI Intervention Group 2 showed sig-

• Waist circumference nificantly greater reductions than the
RCT Group 1: 750 mg/d of metformin only • Insulin levels other groups in weight, BMI, and waist
N = 128. Group 2: 750 mg/d of metformin plus a • Insulin resistance index circumference.
lifestyle intervention Only Intervention Group 3 and the con-
Intervention Group 1, n = 32 (M age =
26.8, 50% male). Group 3: Lifestyle intervention only trol group were included in the meta-
analysis. No significant differences were
Intervention Group 2, n = 32 (M age = Control found between the 2 groups.
26.1, 46.9% male).
Placebo only Intervention group 1 lost 2.86 lb at
Intervention Group 3, n = 32 (M age = 12 wk.
26.4, 53.1% male).

50% male).
Inclusion criteria: Patients aged 18–45,

DSM–IV diagnosis of schizophrenia,
first-episode psychosis
Note. Participant ages are expressed in years unless otherwise noted. ADHD = attention deficit hyperactivity disorder; ADLs = activities of daily living; AUDIT = Alcohol Use Disorders Identification Test; BAI = Beck Anxiety
Inventory; BAS = Burden Assessment Scale; BDI = Beck Depression Inventory; BMI = body mass index; BPRS = Brief Psychiatric Rating Scale; BRFSS = Behavioral Risk Factor Surveillance System; BSI = Brief Symptom
Inventory; CAS = Cunningham Access Survey; CBT = cognitive–behavioral therapy; CDSM = chronic disease self-management; CDSMP = Chronic Disease Self-Management Program; CGI = Clinical Global Impressions;
CGI–I = Clinical Global Impressions–Improvement; CGI–S = Clinical Global Impressions–Severity; DASH = Dietary Approaches to Stop Hypertension; DASS = Depression Anxiety Stress Scale; DSM–IV = Diagnostic and
Statistical Manual of Mental Disorders, 4th ed.; EF = executive function; GAF = Global Assessment of Functioning; GDS = Geriatric Depression Scale; HADS = Hospital Anxiety and Depression Scale; HAM–D17 = 17-item
Hamilton Depression Rating Scale; HAM–D21 = 21-item Hamilton Depression Rating Scale; HbA1c = hemoglobin A1c; HDRS = Hamilton Depression Rating Scale; HPA = hypothalamic–pituitary–adrenal; HRQOL = health-
related quality of life; ICD = International Statistical Classification of Diseases and Related Health Problems; IDS = Inventory of Depressive Symptomatology; ILS = Independent Living Scales; IPAQ = International Physical
Activity Questionnaire; KKW = kilocalories per kilogram of body weight per week; LSMECD = Lorig Self-Management Efficacy in Chronic Disease; M = mean; MADRS = Montgomery–Asberg Depression Rating Scale;
MCAS = Multnomah Community Ability Scale; MDD = major depressive disorder; Mdn = median; MHI = Mental Health Inventory; MMSE = Mini-Mental State Examination; MSPSS = Multidimensional Scale of Perceived
Social Support; NA = not applicable; OEES = Outcomes Expectation for Exercise Scale; 1RM = one-repetition maximum test; PAM = Patient Activation Measure; PANSS = Positive and Negative Syndrome Scale; PECC
= Psychosis Evaluation tool for Common use by Caregivers; PEP = psychoeducational program; PHQ–9 = Patient Health Questionnaire–Depression; PMRT = progressive muscle relaxation training; PSP = Personal and
Social Performance; Q–LES–Q–SF = Quality-of-Life Enjoyment and Satisfaction Questionnaire–Short Form; QOL = quality of life; RCT = randomized controlled trial; SAI = State Anxiety Inventory; SANS = Scale for the
Assessment of Negative Symptoms; SAPS = Scale for Assessment of Positive Symptoms; SCDSES = Stanford Chronic Disease Self-Efficacy Scale; SCDSMP = Stanford Chronic Disease Self-Management Program; SCL–20
= Symptom Checklist Depressive Scale; SEES = Subjective Exercise Experiences Scale; SF–12 = 12-Item Short Form Health Survey; SF–36 = 36-Item Short Form Health Survey; SMI = serious mental illness; SOFS = Social
and Occupational Functioning Scale; SSRI = selective serotonin reuptake inhibitor; STAI = State–Trait Anxiety Inventory; TAU = treatment as usual; TMT = Trail Making Test; TRENDS = Tool for Recognition of Emotions in
Neuropsychiatric Disorders; UCLA CHIPTS = University of California, Los Angeles, Center for HIV Identification, Prevention, and Treatment Services; UPSA = University of California, San Diego, Performance-Based Skills
Assessment; VO2 max = maximal oxygen uptake; WHO = World Health Organization; WHO–DAS = World Health Organization Disability Assessment Scale; WHOQOL–BREF = World Health Organization Quality of Life Brief
scale.
Source for weight loss topic. Brown, C., Geiszler, L. C., Lewis, K. J., & Arbesman, M. (2018). Effectiveness of interventions for weight loss for people with serious mental illness: A systematic review and meta-analysis
A103
Table A.8. Risk-of-Bias Analysis for Intervention Studies Included in the Systematic Review of Interventions to Promote Health and Wellness for Adults Living
With SMI

Selection Bias Blinding of Blinding of Outcome (Attrition Bias)
Participants Assessment
Random and Personnel (Detection Bias): Selective
Sequence Allocation (Performance Patient-Reported Short-Term Long-Term Reporting
Citation Generation Concealment Bias) Outcomes (2–6 wk) (>6 wk) (Reporting Bias)
Weight Loss
Attux et al. (2013) + + – + + + +
Bartels et al. (2013) + + – + + + +
Bartels et al. (2015) + + – + + + +
Brown et al. (2014) + + – – + + +
Cordes et al. (2014) + + ? ? + + +
Daumit et al. (2013) + + ? ? + + +
Forsberg et al. (2008) + + – ? + + +
Goldberg, Reeves, et al. + + ? ? + + +

(2013)
Green et al. (2014) + + + + + + +
Green, Janoff, et al. (2015) + + + + + + +
Iglesias-García et al. (2010) + + ? + + + +
Masa-Font et al. (2015) + + ? + + + +
Mauri et al. (2008) + + ? ? + + +
Methapatara & + + – – + + +
Srisurapanont (2011)
Pagoto et al. (2013) + + ? + + + +

Usher et al. (2013) + + – – + + +
Wu et al. (2008) + + + + + + +
A104
(Continued)
With SMI (cont.)

Relaxation
Behere et al. (2011) + + – + – + –
Chan et al. (2012a) + ? + + – + –
Chen et al. (2009) + ? + – + N/A –
Ikai et al. (2013) + + – – – + –
Ikai et al. (2014) + + – – – + –
Ly et al. (2014) + ? + ? – + –
Sarubin et al. (2014) + ? ? + + – –
Vancampfort, De Hert, + – + + + – +
Knapen, Maurissen,
et al. (2011)
Vancampfort, De Hert, + ? – + + – –
Knapen, Wampers, et al.
(2011)
Varambally et al. (2013) + + – – – + +
Visceglia & Lewis (2011) + – + – – + +
Yeung et al. (2012) + + – + – + +
Exercise
Acil et al. (2008) + – – + – + +
Battaglia et al. (2013) + – – + – – –
A105
Beebe et al. (2010) + – – + – + +
(Continued)
With SMI (cont.)

Beebe et al. (2013) + – – – – +
Belvederi et al. (2015) + ? + + ? ? +
Chalder et al. (2012) + – – + – + +
Danielsson et al. (2014) + – – + – – +
Esquivel et al. (2008) + – – + – + +
Greer et al. (2015) + ? + + – ? +
Hoffman et al. (2011) + + + + ? – –
Kerling et al. (2015) + – – + + – +
Kerse et al. (2010) + + + + – ? +
Krogh et al. (2012) + + + + – ? ?
Lee et al. (2014) + – – + – – +
Loh et al. (2016) + + + + – ? +
Marzolini et al. (2009) ? + + – – – –
Merom et al. (2008) – – + + – – –
Pajonk et al. (2010) – – + – – + –
Pfaff et al. (2014) – – ? + – – –
Rethorst et al. (2013) – – + + – – –
Scheewe et al. (2013) – – + – – – –

Schuch et al. (2011) – ? + ? – – –
A106
Silva et al. (2015) – ? + + – + –
(Continued)
With SMI (cont.)

Trivedi et al. (2011) – + + + – – –
Wedekind et al. (2010) – + + – – – –
Physical Health
Bartels, Pratt, Mueser, ? ? – – + + ?

Naslund, et al. (2014)
Battersby et al. (2013) ? + – + + + +
Chafetz et al. (2008) ? ? ? – + + ?
Druss et al. (2010) + ? ? – + + +
Goldberg, Dickerson, et al. ? ? ? ? – + ?

(2013)
Kelly et al. (2017) + ? ? – + + +
Kelly, Fulginiti, et al. + ? ? – + + +

(2014)
Lambert et al. (2007) + ? ? – + + +
Ludman et al. (2013) + + – + + + +
Note. Categories for risk of bias are as follows: + = low risk of bias; ? = unclear risk of bias; – = high risk of bias; NA = not applicable.
Risk-of-bias table format adapted from “Assessing Risk of Bias in Included Studies,” by J. P. T. Higgins, D. G. Altman, and J. A. C. Sterne, in Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0), by J.
P. T. Higgins and S. Green (Eds.), 2011, London: Cochrane Collaboration. Retrieved from http://handbook-5-1.cochrane.org. Copyright © 2011 by The Cochrane Collaboration.
Source for weight loss topic. Brown, C., Geiszler, L. C., Lewis, K. J., & Arbesman, M. (2018). Effectiveness of interventions for weight loss for people with serious mental illness: A systematic review and meta-analysis
A107
Table A.9. Risk-of-Bias Analysis for Systematic Reviews Included in the Systematic Review of Interventions to Promote Health and Wellness for Adults Living With SMI
List of
Duplicate Comprehensive Status of Included/ Characteristics Quality Quality Methods Used
A Priori Study Literature Publication Excluded of Included of Studies Assessment to Combine Likelihood of Conflict
Design Selection/Data Search as Inclusion Studies Studies Assessed and Used Results Publication of Interest
Citation Included? Extraction? Performed? Criteria? Provided? Provided? Documented? Appropriately? Appropriate? Bias Assessed? Stated?
Weight Loss
Bruins et al. (2014) + ? + – + + + + + + +
Krogh et al. (2014) + ? + – + + – – + – –
Relaxation
Balasubramaniam + + + – + + + + + – +
et al. (2013)
Cramer et al. (2013) + + + – + + + + + – +
Vancampfort et al. + + + + + + + + + – +
(2013)
Vancampfort, Vanste + + + + + + + + + – +
elandt, et al. (2012)
Exercise
Farholm & Sørenson + ? + – + + + + + – –

(2016)
Firth et al. (2015) + ? + – + + + + + – +
Holley et al. (2011) + – + – + + + + + – –
Jayakody et al. (2014) + + + – + + + + + – +
Pearsall et al. (2014) + + + + + + + + + + +
Rosenbaum et al. + + + + + + + + + – +
(2014)
Silveira et al. (2013) + ? + – + + + + + – +
Stubbs et al. (2016) + + + – + + + + + + +
Vancampfort, Probst, + + + – + + + + + – +
et al. (2012)
A108
(Continued)
Table A.9. Risk-of-Bias Analysis for Systematic Reviews Included in the Systematic Review of Interventions to Promote Health and Wellness for Adults Living With SMI (cont.)
List of
Duplicate Comprehensive Status of Included/ Characteristics Quality Quality Methods Used
A Priori Study Literature Publication Excluded of Included of Studies Assessment to Combine Likelihood of Conflict
Design Selection/Data Search as Inclusion Studies Studies Assessed and Used Results Publication of Interest
Citation Included? Extraction? Performed? Criteria? Provided? Provided? Documented? Appropriately? Appropriate? Bias Assessed? Stated?
Physical Health
Bradford et al. (2013) + + + + + + + + + – +
Kelly, Fenwick, et al. + + + – + + – – + – +

(2014)
Siantz & Aranda + ? + – + + + + + – –

(2014)
Tosh et al. (2011) + + + + + + + + + – +
Van Hasselt et al. + ? + + + + – – + – –

(2013)
Whiteman et al. + ? + – + + + + + – +
(2016)
Risk-of-bias table format adapted from “Development of AMSTAR: A Measurement Tool to Assess the Methodological Quality of Systematic Reviews,” by B. J. Shea, J. M. Grimshaw, G. A. Wells, M. Boers, N. Anderson, C. Hamel, . . .
L. M. Bouter, 2007, BMC Medical Research Methodology, 7, p. 10. https:/doi.org/10.1186/1471-2288-7-10
This table is a product of AOTA’s Evidence-Based Practice Project and the American Journal of Occupational Therapy. Copyright © 2019 by the American Occupational Therapy Association. It may be freely reproduced for personal use
in clinical or educational settings as long as the source is cited. All other uses require written permission from the American Occupational Therapy Association. To apply, visit www.copyright.com.
Source for weight loss topic. Brown, C., Geiszler, L. C., Lewis, K. J., & Arbesman, M. (2018). Effectiveness of interventions for weight loss for people with serious mental illness: A systematic review and meta-analysis (Suppl. Table 3).
A109
Table A.10. Evidence Table for the Systematic Review of Early Intervention for Adolescents and Young Adults Living With SMI

Cognitive Remediation
Holzer et al. (2014) Level I Intervention • DSM–IV The intervention group showed significant
8-wk specialized CACR program consist- • SIPS improvement in visuospatial abilities
RCT ing of 8 modules designed to develop and • RBANS compared with the control group. Both
N = 28 (age range = 13–18, gender not remediate cognitive abilities, motor skills, • PANSS groups showed improvements in atten-
reported). self-control, and self-esteem with con- • SOFAS tion, memory, general psychopathology,
sistent staff support offered; 16 45-min • Health of Our Nation Outcome Scale and social and occupational functioning.
Intervention group, n = 15 (11 FEP, 4 individual sessions for Children and Adolescents
CHR; M age = 15.4). Interpretation of results is limited by the
Control small sample size.
Control group, n = 13 (8 FEP, 5 CHR; M Commercial nonviolent action computer
age = 15.7). games; 2 half-hour sessions over 8 wk
Inclusion criteria: FEP or CHR
Lee et al. (2013) Level I Intervention • WTAR The intervention group improved signifi-
CR consisting of psychoeducation • HDRS–17 cantly compared with the control group in
RCT regarding cognitive deficits and relevant • BPRS–E immediate learning, memory, and psycho-
N = 55 (M age = 22.8). compensatory strategies, therapist-led • Trails A social functioning.
drill-and-practice group activities, and • Category Fluency
Intervention group, n = 28 (42.9% men). computer-assisted cognitive training • Longest Digit Span Forward
• Longest Digit Span Backward
Control group, n = 27 (59.3% men). Control • Cambridge Neuropsychological Test
TAU Automated Battery
Inclusion criteria: Lifetime history of
a single episode of major depressive • Rapid Visual Processing Hits
disorder or psychotic disorder; clinically • Logical Memory I
stable; fluent in English; no current • RAVLT Total
substance dependence, developmental • Logical Memory II Percentage
disorder, neurological condition, history Retention
of traumatic brain injury, current use of • RAVLT Retention
1st-generation antipsychotic medication, • Rey–Osterrieth Complex Figure
or IQ <80 3-Minute Recall
• Trails B
• Intra–Extra Dimensional Set Shift Errors
• Letter Fluency Test
• SFS
(Continued)
A110
Table A.10. Evidence Table for the Systematic Review of Early Intervention for Adolescents and Young Adults Living With SMI (cont.)

Loewy et al. (2016) Level I Intervention • SOPS The intervention group showed significant
Targeted auditory training program • GF–R improvement in verbal memory perfor-
RCT consisting of computerized exercises • GF–S mance compared with the control group.
N = 83. designed to improve speed and accuracy • MATRICS
of auditory information processing while Small nonsignificant positive effect sizes
Intervention group, n = 50 (M age = engaging auditory and verbal working were reported in global cognition and
17.8, 52% men). memory; 1 hr/day, 5 days/wk over 8 wk problem solving.

49% men). Computer games
Inclusion criteria: 1 of 3 syndromes on
the SIPS—attenuated positive symptom
syndrome, brief intermittent psychosis
prodromal syndrome, or genetic risk and
deterioration prodromal syndrome; good
general physical health; aged 12–30;
fluent and proficient in English; IQ ≥70;
no neurological disorder; no substance
dependence in past year or current use
that would interfere with training
Mendella et al. (2015) Level I Intervention • MCCB The intervention group experienced
Compensatory cognitive training • WTAR improvements in global cognition and
RCT pilot • UPSA–B social cognition.
Control • PANSS
N = 27 (M age = 25, 74.1% men). TAU No significant effects were found for
• Calgary Depression Scale for
Intervention group, n = 16. Schizophrenia functional capacity or symptoms.
Inclusion criteria: Diagnosis of primary

psychotic disorder, aged 18–35
Østergaard Level I Intervention • UPSA–B No significant effect of CR on functional

Christensen et al. EI service + 16-wk CR program • MCCB capacity was found (UPSA–B).
(2014) RCT (NEUROCOM) consisting of computerized • Trails B
exercises and engagement in practical, • Hopkins Verbal Learning Test–Revised The intervention group showed significant
N = 117 (M age = 25). improvements with medium effect sizes in
everyday tasks based in errorless learning • PANSS
Intervention group, n = 60 (58.3% men). and scaffolding principles • RSES verbal learning at postintervention and at
12-mo follow-up and in working memory
Control group, n = 57 (49.1% men). Control at 12-mo follow-up.
EI service
A111
Inclusion criteria: 1st episode of schizophre-

nia spectrum disorder, stable for ≥1 mo
(Continued)

Puig et al. (2014) Level I Intervention • Subtests of Wechsler Memory Scales, CR therapy had a greater beneficial effect
20 wk of CR therapy (paper-and-pencil 3rd ed. on verbal memory, working memory,
RCT (single blind, parallel group) task using errorless learning) + TAU • Subtests of RAVLT and executive functions at the end of
N = 50 (M age = 17, 52% men). • Subtests of Wechsler Intelligence Scale intervention.
Control for Children, 4th ed.
Intervention group, n = 25. TAU • Subtests of WAIS, 3rd ed. The intervention group made greater
• Trails A improvements in daily living skills and
Control group, n = 25. global functioning at the end of the inter-
• Subtests of Controlled Oral Word
Association Tests vention, but functional gains were not
Inclusion criteria: Aged 12–18,
• Trails B maintained 3 mo after the intervention
DSM–IV–TR schizophrenia or schizoaffec-
• PANSS ended.
tive disorder, onset at age 17 or earlier
• CDS Parent burden decreased in the CR group.
• Life Skills Profile
• Vineland Adaptive Behavior Scales No significant differences were found in
• C–GAS C–GAS scores or self-esteem.
• RSES
• Caregiver Burden Inventory
Rauchensteiner et al. Level II Intervention • VLMT The intervention group increased perfor-
(2011) COGPACK Version 6.06, a computerized • CPT–IP mance on the VLMT after distraction and
Pre–post cognitive training program for partici- 20 min and on no. of correct hits on the
N = 26. pants at risk for schizophrenia; 10 ses- Shapes subtest of the CPT–IP, whereas
sions over 4 wk the control group did not.
Intervention group, n = 10 (M age = 27,
gender not reported). Control Findings indicate that people at risk for
Same intervention for participants diag- schizophrenia can improve long-term
Control group, n = 16 (M age = 30, gen- nosed with schizophrenia memory functions, attention, and con-
der not reported). centration after cognitive training with
COGPACK.
Inclusion criteria: ≥2 basic symptoms
from the cognitive disturbances category
in the prediction list of the Revised BSABS
for ≥1 yr with score of 3 within past 3
mo, or ≥1 attenuated positive symptoms
on the SOPS, or brief limited intermittent
psychotic symptoms with PANSS score of
≥4 with duration <1 wk within past 3 mo
(Continued)
A112

Cognitive–Behavioral Therapy
Addington et al. (2011) Level I Intervention • SIPS No significant differences between groups
Manualized problem-focused time-limited • SCID were found after treatment, suggesting
Single-blind RCT CBT, ≤20 sessions within 6 mo • S AS that there may be no difference between
N = 51 (M age = 21 [range = 14–30], • CDS treatments, that the sample size was low
Control • Social Interaction Anxiety Scale for an effect, or that too much time was
70.6% men). Supportive therapy • SFS spent on engagement with participants in
Intervention group, n = 27. the intervention group.
Control group, n = 24. Implementers may not have followed the
CBT model well, providing more emphasis
Inclusion criteria: Youth with CHR meet-
on engagement and less on core CBT
ing criteria for prodromal states using
strategies.
the SIPS
The intervention group had no conver-
sions to psychosis and had a faster reduc-
tion in positive symptoms compared with
the control group.
Bechdolf et al. (2007) Level I Intervention • SAS–II 67 study participants completed baseline
Specially designed CBT offered in indi- and posttreatment SAS–II assessments.
RCT vidual and group structured formats
Both groups showed improvements in
N = 113 (M age = 25 [range = 19–30.5]; focused on thoughts, perceptions, illness SAS–II scores, but no significant differ-
gender not reported). symptoms, and problems with family and
occupational functioning ences between groups were found at
Inclusion criteria: Help-seeking youth with posttreatment.
CHR Control
Standard care consisting of individual counsel-
ing focused on basic assessment, psychoedu-
cation, and support in unstructured sessions
with warm, genuine, empathic delivery
Brent et al. (2015) Level I Intervention • C–GAS SQ assessed only at 75 mo favored inter-
Cognitive–behavioral prevention, a • SQ vention participants whose parent was
RCT modified version of the Coping with not depressed at time of intervention. No
N = 316 initially, 278 at 75-mo follow-up Depression for Adolescents program benefit was found for those whose parent
(M age = 14.85, 40.6% men). emphasizing cognitive restructuring was depressed at intervention time.
and problem solving, plus usual care; 8
Intervention group, n = 139 at 6 yr. weekly 90-min sessions followed by 6 No group difference in mean C–GAS
monthly booster sessions scores was found at 75 mo.
Control group, n = 139 at 6 yr.
Control
Inclusion criteria: Aged 13–17, ≥1 parent
Usual care alone
A113
with current or prior depressive episodes
(Continued)

Clarke et al. (2001) Level I Intervention • Achenbach Child Behavior Checklist The intervention group demonstrated
Cognitive therapy prevention program, 15 • K–SADS fewer reported depressed days, reduced
RCT small-group 1-hr sessions plus standard • CES–D depressive symptoms, and reduced sui-
N = 94 (age range = 13–18). care in an HMO, plus 3 parent education • HDRS cidal ideation at 12 mo. Clinically signifi-
sessions to inform parents about topics • GAF cant preventive effects of treatment were
Intervention group, n = 45 (M age = discussed and skills taught to the youth found in regard to functioning (GAF), but
14.4, 46.7% men). at 2 yr, preventive effects of treatment
Control seemed to fade, suggesting that periodic
Control group, n = 49 (M age = 14.7, Standard care in an HMO booster sessions may extend preventive
34.7% men).
effects.
Inclusion criteria: Subsyndromal symp-
toms of depression (not diagnosable),
parent in treatment for major depression
or dysthymia or received treatment within
past 12 mo and still taking medication
Gleeson et al. (2013) Level I Intervention • SCID At 12 mo, relapse rates in the RPT
Individual and family cognitive–behavioral • Montgomery Asberg Depression Rating group were significantly lower than in
RCT RPT plus TAU with psychoeducational Scale the EI group, and time to relapse was
N = 81 (age range = 15–25, 63.0% components about relapse risk offered • SANS significantly delayed. However, these
men). over 7 mo • BPRS differences were not sustained at 18,
• Scale for the Unawareness of Mental 24, and 30 mo, indicating the need for
Intervention group, n = 41 (65.9% men). Control Disorder further research about longer treatment
Specialized EI services for FEP including • Medication Adherence Rating Scale interventions. In fact, SOFAS scores in the
Control group, n = 40 (60.0% men). case management and medication moni- • WTAR control group continued to improve up
toring with a psychiatrist • Premorbid Adjustment Scale to 30 mo, but in the intervention group,
Inclusion criteria: FEP diagnosis, <6 mo
on antipsychotic medication, mild or • SOFAS SOFAS scores improved until 24 mo, then
remitted positive symptoms • QLS, Australian version declined to baseline level by 30 mo.
Hutton & Taylor (2014) Level I Intervention • GAF CBT interventions reduced risk of conver-
Time-limited, manualized CBT designed • SOFAS sion to psychosis at 6, 12, 18, and 24
Systematic review and meta-analysis to prevent psychosis in nonmedicated • SAS–II mo and reduced symptoms at 1 yr. These
N = 6 RCTs. individuals with CHR • QOL studies highlight the positive effects
of 1 psychosocial intervention without
N = 800 participants. Control medication.
TAU or nonspecific supportive therapy
Inclusion criteria: RCTs with low risk of
bias of CBT-informed care for nonmedi-
cated youth with CHR
(Continued)
A114

Jackson et al. (2008) Level I Intervention • SCID Improvements in functioning and symp-
Time-limited, manualized CBT program • BPRS, Psychotic subscale tom reduction were found in both groups,
RCT called Active Cognitive Therapy for Early • SANS but the intervention group showed signifi-
N = 62 (age range = 15–25). Psychosis • SOFAS cantly higher midtreatment functioning.
Over time, gains were lost in both groups.
Intervention group, n = 31 (M age = Control Neither group showed a reduction in
22.1, 61.3% men). Befriending, a manualized treatment positive or negative symptoms.
offering opportunities for neutral conver-
Control group, n = 31 (M age = 22.5, sation or activities with a primary thera-
83.9% men). pist to maintain engagement
Inclusion criteria: Youth with FEP
Stice et al. (2008) Level I Intervention • 16 items adapted from the K–SADS Intervention Group 1 had significant
Group 1: Group CBT • BDI reductions in depressive symptoms com-
RCT • 17 items adapted from the Social pared with the control group at 6 wk and
Group 2: Supportive expressive therapy Adjustment Scale-Self Report for Youth 6 mo.
N = 341 (M age = 15.6, 44% men).
Group 3: Bibliotherapy • Substance use
Intervention Group 1, n = 89. • Eating Disorder Diagnostic Interview Intervention Group 1 had significant
Control reductions in depressive symptoms com-
Intervention Group 2, n = 88. Assessment only pared with Intervention Groups 2 and 3
at 6 wk but not at 6 mo. Groups 2 and
Intervention Group 3, n = 80.
3 had significantly stronger reductions in
Control group, n = 84. depressive symptoms compared with the
control group.
Inclusion criteria: Students who scored
≥20 on the CES–D scale and returned the No significant differences in rates of
consent form major depression onset were found across
the 3 intervention groups.
CBT produced stronger effects (small

to moderate) for social adjustment and
substance use at 6 mo than all 3 other
conditions.
(Continued)
A115

Yung et al. (2011) Level I Intervention • Comprehensive Assessment of At-Risk No difference was found across groups in
Group 1: Cognitive therapy + risperidone Mental States transition to psychotic disorder.
RCT • BPRS
Group 2: Cognitive therapy + placebo • SANS All 4 groups improved significantly in
N = 115 (age and gender not BPRS total, BPRS Psychotic subscale, and
reported). Control • HDRS
• GAF HDRS scores.
Group 1: Supportive therapy + placebo
Intervention Group 1, n = 43. • QLS All groups except Intervention Group 1
Group 2: Agreed to follow-up assessment significantly increased in functioning.
Intervention Group 2, n = 44. but not randomization
Control Group 1, n = 28. Both control groups improved signifi-
cantly in negative symptoms.
Control Group 1 showed reduced affec-
Inclusion criteria: Aged 14–30, area tive flattening.
resident, attenuated psychotic symptoms
within previous 12 mo or brief limited Only Control Group 2 experienced signifi-
intermittent psychotic symptoms within cant increases in QLS scores.
previous 12 mo or schizotypal personal-
ity disorder or family history of psychotic
disorder in 1st-degree relative plus per-
sistent low functioning for ≥1 mo within
previous 12 mo
Supported Employment and Supported Education
Baksheev et al. (2012) Level I Intervention • BPRS Demographic and clinical factors did not
IPS + TAU to investigate demographic • SANS significantly predict vocational recovery in
RCT and clinical predictors of vocational recov- • CESD–R the final multivariate analysis.
N = 41 (M age = 21 [range = 15–24], ery, defined as having gained competi- • SCID
tive employment or entered a course of • QLS Vocational recovery was predicted solely
80.5% men). by participant group; intervention partici-
education • SOFAS
Intervention group, n = 20. pants were >16× more likely to secure
Control a competitive employment position or
Control group, n = 21. TAU consisting of individual case man- participate in an educational activity dur-
agement and medical review, referral ing the follow-up period compared with
Inclusion criteria: Youth with early FEP
to external vocational agencies, and control participants.
involvement with the agency’s group
program
(Continued)
A116

Bond, Drake, & Level I Intervention • Competitive employment at baseline Supported employment services increased
Luciano (2015) EI programs with supported employment and follow-up (primary) employment rates of participants in EI
Systematic review services (e.g., IPS), unspecified vocational • Any vocational outcomes (including programs but not engagement in educa-
N = 28 studies (12 EI studies without services, or no vocational services occupational functioning scales) tional activities.
identified vocational component, N = • Combined employment and educa-
tional outcomes in a single measure No conclusions could be drawn about the
3,091 participants; 5 EI + nonstandard- effectiveness of unspecified vocational
ized vocational assistance, N = 396; 11 EI • Rates of enrollment in education
services because of the heterogeneity and
+ supported employment, N = 1,370). descriptive nature of the studies in this area.
Inclusion criteria: Longitudinal studies of No conclusions could be drawn about the
EI programs with ≥10 participants report- effect on employment or education outcomes
ing vocational or educational outcomes of EI programs without vocational services
(defined broadly to include a range of because of extreme variability in measures of
indicators and scales); uncontrolled, quasi- employment and education outcomes.
experimental, or experimental study design
Dudley et al. (2014) Level II Intervention • Employed or in studies Employment for the intervention group
IPS opportunities guided by an EI team increased during the treatment phase but
Naturalistic comparison of 2 matched groups vocational specialist, with vocational declined by 6 mo after termination of IPS
N = 161 (age range = 14–35). participation assessments at 6 mo prein- services.
tervention, 1 mo preintervention, and 12
Intervention group, n = 81 (M age = mo postintervention
24.2, 75% men).
Control
Control group, n = 80 (M age = 25.3, EI services without a vocational specialist,
72% men). with vocational participation assessments
at same time points
Inclusion criteria: Distressing and/or dis-
abling psychotic symptoms for ≥7 days
Killackey et al. (2008) Level I Intervention • SCID The intervention group had better
IPS + TAU for 6 mo • BPRS employment outcomes; more IPS partici-
RCT • SANS pants found and kept jobs (13 vs. 2) and
Control • QLS worked more hours per week.
N = 41. TAU • CESD–R
Intervention group, n = 20 (M age = • SOFAS 4 participants in each group enrolled in
21.29, 80.0% men). educational studies during the trial.

81.0% men).
Inclusion criteria: Individuals with FEP

interested in competitive employment, with
≥6 mo remaining in treatment program
A117
(Continued)

Major et al. (2010) Level II Intervention • Vocational status, defined as gaining The intervention group had significantly
Specialist occupational therapy–led or returning to competitive employ- improved vocational status compared
Naturalistic prospective cohort vocational services consisting of compre- ment (competitively assessed work, with the control group.
N = 114 (M age = 24, 62% men). hensive baseline assessment, individual paid at market rate) or an educational
support, liaison with workplaces and edu- activity clearly leading to a nationally
Intervention group, n = 44. cational institutions, provision of groups recognized vocational qualification or
(both vocation-oriented and less specific degree, entered into at any point in the
social groups), and specific skills training follow-up period
Inclusion criteria: FEP (psychotic symptoms (e.g., interview techniques)
persisting ≥1 wk or resulting in hospital
Control
admission or crisis team intervention); no
No specialist vocational services
antipsychotic medication at therapeutic
dose for ≥6 wk, previous diagnosis of psy-
chotic illness, prodromal status, or symp-
toms secondary to personality disorder,
posttraumatic stress disorder, or drug use
Rinaldi et al. (2010) Level III Intervention Employment or educational status Open employment outcomes improved
IPS + education over 2 yr, peaking at 12 mo, but attrition
Pre–post was high (166 began the study but only
Control 67 were evaluated at 2 yr).
N = 166 (baseline and 6 mo), N = 142 (12 No control
mo), N = 106 (18 mo), N = 67 (24 mo) (M Mainstream education or training
age = 22 [range = 17–32], 69% men). improved in the 1st 6 mo but then
Inclusion criteria: EI clients who received declined through the remaining 18 mo.
vocational intervention
Family Psychoeducation
Calvo et al. (2014) Level I Intervention • DSM–IV Psychoeducation reduced relapse rates,
Psychoeducation in a structured, problem- • PANSS, Spanish version reduced negative symptoms, and pro-
RCT solving group format offered by same 2 • C–GAS moted reduced medication dosage during
N = 55 (age range = 14–18). therapists to teens and parents separately • Family Environment Scale intervention.
plus written materials; 12 90-min ses- • Specially designed questionnaire to
Intervention group, n = 27 (M age = sions every 15 days record no. of hospital admissions, total Psychoeducation promoted more youth
16.4, 59.3% men). no. of psychiatric hospitalizations, no. interest in recreation. Both groups
Control of ER visits showed improved positive symptoms and
Control group, n = 28 (M age = 16.5, Nonstructured supportive group format functioning.
64.3% men). offered by same 2 therapists to teens and
parents separately with no written materi-
Inclusion criteria: Early FEP, ≥1 positive
als; 12 90-min sessions every 15 days

psychotic symptom (delusions or halluci-
nations) before age 18, DSM–IV diagno-
sis of major mental illness with psychosis
A118
(Continued)

Calvo et al. (2015) Level I Follow-up review of 89% of Calvo et al. • Schedule for Affective Disorders and 2-yr postintervention effects were sus-
(2014) participants to understand sus- Schizophrenia for School-Age Children tained for the psychoeducation interven-
RCT 2-yr follow-up tained effects in intervention and control • Analysis of hospital admissions and tion group, who had fewer ER visits
Initial N = 55 (age range = 14–18). groups visits statistics than the control group (13% vs. 50%),
suggesting that psychoeducation helped
Intervention group, n = 27 (M age = families develop tools for dealing with
16.4, 59.3% men). crises.
Control group, n = 28 (M age = 16.5, 2-yr PANSS total scores improved sig-
64.3% men). nificantly for both groups, but PANSS
General Symptom scores improved signifi-
Inclusion criteria: Early FEP
cantly only in the intervention group.
Granö et al. (2009) Level III Intervention • Screen for Prodromal Symptoms of Overall functioning and QOL improved
Family-oriented meetings focused on Psychosis with the intervention, which promoted
Single-group pre–post reducing stress in all life areas, held in • BSABS engagement with school and work. By
N = 28 (M age = 14.5 [range = 12–18], youths’ natural surroundings (home, • GAF follow-up, prepsychotic, depression, and
35.7% men). school) for as long as necessary for youths • QLS anxiety symptoms had improved at the
to feel secure while supporting function- group level.
Inclusion criteria: CHR for psychosis with ing; participants in meetings included cli-
no previous psychotic episodes ents, family members, and professionals
from the community and treatment team
Granö et al. (2016) Level II Intervention • Global Assessment of No clinical group differences were found
Supportive sessions as needed in natural Functioning–Modified at baseline, but intervention participants
2-group comparison study community surroundings with a focus on • BAI were younger.
N = 56 (age range = 12–22). reducing stress through strengthening • BDI–II
family communication and support, based • BHS Intervention participants experienced
Intervention group, n = 28 (M age = on the Family- and Community-Oriented • SIPS greater improvements in function (20%
15.5, 32.1% men). Integrative Treatment Model, which vs. 6%), depression, and hopelessness
incorporates elements of family therapy, compared with the control group.
treatment for emerging psychosis, open
32.1% men).
dialogue, and CBT; sessions included the
Inclusion criteria: Youth with CHR for youth with CHR, family members, and
psychosis primary health care workers
Control
TAU
(Continued)
A119

Harder et al. (2014) Level II Intervention • Operational Criteria Checklist for The intervention group showed significant
Manualized supportive psychodynamic psy- Psychotic Illness improvements in social functioning, lower
Multisite comparison chotherapy, which uses the developmental • GAF positive symptoms, and fewer overall
N = 269 (age range = 16–35, 67.3% psychopathology approach to help clients • Strauss Carpenter Scale symptoms compared with the control
men). understand pathways to illness and the • PANSS group, but effects were not sustained at
impact on social functioning and develop- 5-yr follow-up.
Intervention group, n = 119. mental processes, plus standard treatment,
offered for 3 yr and followed up to 5 yr
Control
Inclusion criteria: Youth on the schizo-
Standard treatment consisting of as-
phrenia spectrum with FEP
needed contact with physicians and staff
nurses, short psychoeducational pro-
grams, group meetings, medical care, and
referrals to outside available resources
McFarlane et al. (2015) Level II Intervention • SIPS The intervention group had significantly
Family-aided Assertive Community • GAF reduced positive, negative, disorganized,
Risk-based allocation (regression Treatment • GF–R and general symptoms; increased GAF
discontinuity) • GF–S scores; and superior overall improvement
Control • QLS compared with the control group.
N = 337 (M age = 16.6, gender not reported). Community care
• SCID
Inclusion criteria: Aged 12–25, living in

site’s catchment area, score of ≥1 on any
positive symptom scale or 3 on any nega-
tive symptom scale of the SOPS
Miklowitz et al. (2014) Level I Intervention • SIPS/SOPS The intervention group had greater
Family-focused therapy consisting of psy- • GAF improvement in attenuated positive
RCT choeducation and training in communica- • GF–R symptoms over 6 mo compared with the
N = 129 participants (M age = 17.4, tion and problem solving • GF–S control group.
57.4% men) and their families. Control Both groups showed significant improve-
Intervention group, n = 66. Enhanced care ments in negative symptoms over 6 mo.
Both groups improved in social and role
Control group, n = 63. functioning.
Inclusion criteria: Aged 12–35; attenu- Intervention participants aged >20 and
ated positive symptoms, brief intermittent control participants aged 16–19 had
psychosis, or genetic risk and deteriora- greater functional improvement.
A120
tion; met criteria for 1 of 3 prodromal
syndromes assessed by SIPS and SOPS
(Continued)

O’Brien et al. (2014) Level I Intervention 10-min family problem solving interaction Youth and family members or significant
Family-focused therapy consisting of psy- (coded by trained raters) others who participated in the interven-
RCT choeducation and training in communication demonstrated improved constructive
N = 129 (66 youth [M age = 16.9] and tion and problem solving communication during family problem-
63 family members; gender not reported). Control solving interactions compared with those
in the control group.
Intervention group, n = 66. Enhanced care
Inclusion criteria: Aged 12–35 yr;

attenuated positive symptoms, brief
intermittent psychosis, or genetic risk and
deterioration
Note. Participant ages are expressed in years unless otherwise noted. BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; BHS = Beck Hopelessness Scale; BPRS = Brief Psychiatric Rating Scale; BPRS-E = Brief
Psychiatric Rating Scale–Expanded; BSABS = Bonn Scale for the Assessment of Basic Symptoms; CACR = computer-assisted cognitive remediation; CBT = cognitive–behavioral therapy; CDS = Calgary Depression Scale;
CES–D = Center for Epidemiologic Studies Depression Scale; CESD–R = Center for Epidemiologic Studies Depression Scale–Revised; C–GAS = Children’s Global Assessment Scale; CHR = clinical high risk for psychosis; CPT–IP
= Continuous Performance Test, Identical Pairs version; CR = cognitive remediation; DSM = Diagnostic and Statistical Manual of Mental Disorders; EF = executive function; EI = early intervention; ER = emergency room;
FEP = first-episode psychosis; GAF = Global Assessment of Functioning; GF–R = Global Functioning–Role adjustment; GF–S = Global Functioning–Social scales; HDRS = Hamilton Depression Rating Scale; HMO = health
maintenance organization; IPS = Individual Placement and Support; K–SADS = Schedule for Affective Disorders and Schizophrenia for School-Age Children; M = mean; MATRICS = Measurement and Treatment Research
to Improve Cognition in Schizophrenia; MCCB = MATRICS Consensus Cognitive Battery; PANSS = Positive and Negative Syndrome Scale; QLS = Quality of Life Scale; QOL = quality of life; RAVLT = Rey Auditory Verbal
Learning Test; RBANS = Repeatable Battery for the Assessment of Neuropsychological Status; RCT = randomized controlled trial; RPT = relapse prevention therapy; RSES = Rosenberg Self-Esteem Scale; SANS = Scale for the
Assessment of Negative Symptoms; SAS = Social Attainment Scale; SCID = Structured Clinical Interview for DSM–IV; SFS = Social Functioning Scale; SIPS = Structured Interview for Prodromal Symptoms; SOFAS = Social and
Occupational Functioning Assessment Scale; SOPS = Scale of Prodromal Syndromes; SQ = Status Questionnaire; TAU = treatment as usual; Trails A = Trail Making Test Part A; Trails B = Trail Making Test Part B; UPSA–B =
University of California, San Diego, Performance Skills Assessment; VLMT = Verbal Learning Memory Test; WAIS = Wechsler Adult Intelligence Scale; WTAR = Wechsler Test of Adult Reading.
Source. Read, H., Roush, S., & Downing, D. (2018). Early intervention in mental health for adolescents and young adults: A systematic review (Suppl. Table 1). American Journal of Occupational Therapy, 72, 7205190040.
A121
Table A.11. Risk-of-Bias Analysis for Intervention Studies Included in the Systematic Review of Early Intervention for Adolescents and Young Adults Living
With SMI

Selection Bias Blinding (Attrition Bias)
Blinding of of Patient- Selective
Random Participants Reported Reporting
Sequence Allocation and Personnel Outcomes Short Term Long Term (Reporting
Citation Generation Concealment (Performance Bias) (Detection Bias) (2–6 wk) (>6 wk) Bias)
Addington et al. (2011) + ? ? + + + +
Baksheev et al. (2012) + + – – ? ? +
Bechdolf et al. (2007) + + – – NA – +
Brent et al. (2015) + + + – ? ? +
Calvo et al. (2014) + ? – + NA – +
Calvo et al. (2015) + ? – + NA – +
Clarke et al. (2001) + + – + + + +
Dudley et al. (2014) – – – – NA – –
Gleeson et al. (2013) + + – + NA + +
Granö et al. (2009) – – – – ? ? +
Granö et al. (2016) – – ? ? NA ? +
Harder et al. (2014) – – – – NA – +
Holzer et al. (2014) + + – + NA – +
Jackson et al. (2008) ? ? – + – – +
Killackey et al. (2008) + + – – NA + +
Lee et al. (2013) – – – – NA + +
Loewy et al. (2016) ? ? ? + NA – +
Major et al. (2010) – – – ? + + +

McFarlane et al. (2015) – – – + NA + +
A122
(Continued)
Table A.11. Risk-of-Bias Analysis for Intervention Studies Included in the Systematic Review of Early Intervention for Adolescents and Young Adults Living
With SMI (cont.)

Selection Bias Blinding (Attrition Bias)
Blinding of of Patient- Selective
Random Participants Reported Reporting
Sequence Allocation and Personnel Outcomes Short Term Long Term (Reporting
Mendella et al. (2015) + + – – NA + +
Miklowitz et al. (2014) ? ? – + NA + +
O’Brien et al. (2014) + ? – + NA + +
Østergaard Christensen + + – + NA + +
et al. (2014)
Puig et al. (2014) ? – – + NA + +
Rauchensteiner et al. – – – – ? NA +
(2011)
Rinaldi et al. (2010) – – – – NA – –
Stice et al. (2008) + ? – + + + +
Yung et al. (2011) + + – + NA + +
Note. Categories for risk of bias are as follows: + = low risk of bias; ? = unclear risk of bias; – = high risk of bias. NA = not applicable.
Risk-of-bias table format adapted from “Assessing Risk of Bias in Included Studies,” by J. P. T. Higgins, D. G. Altman, and J. A. C. Sterne, in Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0), by
J. P. T. Higgins and S. Green (Eds.), 2011, London: Cochrane Collaboration. Retrieved from http://handbook-5-1.cochrane.org. Copyright © 2011 by The Cochrane Collaboration.
Source. Read, H., Roush, S., & Downing, D. (2018). Early intervention in mental health for adolescents and young adults: A systematic review (Suppl. Table 2). American Journal of Occupational Therapy, 72, 7205190040.
A123
Table A.12. Risk-of-Bias Analysis for Systematic Reviews Included in the Systematic Review of Early Intervention for Adolescents and Young Adults Living
With SMI
Duplicate Status of List of Included/ Characteristics Quality Methods Used Likelihood of

A Priori Study Comprehensive Publication Excluded of Included of Studies Quality to Combine Publication Conflict
Design Selection/Data Literature Search as Inclusion Studies Studies Assessed and Assessment Used Results Bias of Interest
Citation Included? Extraction? Performed? Criteria? Provided? Provided? Documented? Appropriately? Appropriate? Assessed? Stated?
Bond, Drake, & + + – – – + – – + – +

Luciano (2015)
Hutton & Taylor + + + + + + + + + – +

(2014)
Note. Risk-of-bias categories: + = low risk of bias; ? = unclear risk of bias; – = high risk of bias. NA = not applicable.
Hamel, . . . L. M. Bouter, 2007, BMC Medical Research Methodology, 7, p. 10. https:/doi.org/10.1186/1471-2288-7-10
This table is a product of AOTA’s Evidence-Based Practice Project and the American Journal of Occupational Therapy. Copyright © 2018 by the American Occupational Therapy Association. It may be freely reproduced for per-
sonal use in clinical or educational settings as long as the source is cited. All other uses require written permission from the American Occupational Therapy Association. To apply, visit www.copyright.com.
Source: Read, H., Roush, S., & Downing, D. (2018). Early intervention in mental health for adolescents and young adults: A systematic review (Suppl. Table 3). American Journal of Occupational Therapy, 72, 7205190040.
A124
Table A.13. Evidence Table for the Systematic Review of Interventions to Reduce Internalized Stigma for Adults Living With SMI
Level of Evidence/Study
Design/Participants/Inclusion
Author/Year Criteria Intervention and Control Outcome Measures Results
Aho-Mustonen et al. Level I Intervention • PSQ PSQ scores decreased during the interven-
(2011) Group psychoeducation program • RSES tion phase in both groups, but much more
RCT based on Ascher-Svanum and Krause’s • Brief Psychiatric Rating Scale in the control group, which appeared to
N = 39 (M age = 39.6). Psychoeducational Groups for Patients • DAI–10 be a negative treatment effect for group
With Schizophrenia and the stress– • SUMD psychoeducation (d = −.59).
Intervention group, n = 19. vulnerability model of schizophrenia, • KASQ
45–60 min 1×/wk for 8 wk RSES scores increased significantly for the
Control group, n = 20. intervention group, but change was not
Control significant at 3-mo follow-up.
Inclusion criteria: Forensic inpatients
TAU
at a hospital in Finland, primary diag- KASQ scores showed no significant
nosis of schizophrenia or schizoaffec- change posttreatment, but the interven-
tive disorder tion group had significantly increased
scores at 3-mo follow-up.
No other outcome measures yielded sig-

nificant findings.
Conner et al. (2015) Level III Intervention • ISMI PDDS scores were significantly reduced,
Face-to-face, unstructured sessions with • PDDS M change = 4.14, t = 2.691, p < .05,
Pretest–posttest a peer educator who used motivational and ISMI scores were significantly
N = 19 (M age = 67). interviewing over 3 mo, with an average reduced, M change = 8.142, t = 2.566,
of 9 contacts p < .05.
Inclusion criteria: Depressive episode
with at least moderate symptoms; Control
clients of 2 community-based None
primary care health centers and
a social service agency in a pre-
dominantly low-income and African-
American community in an eastern
U.S. city
(Continued)
A125
Table A.13. Evidence Table for the Systematic Review of Interventions to Reduce Internalized Stigma for Adults Living With SMI (cont.)
Corrigan et al. (2015) Level I Intervention • SSMIS The intervention group showed signifi-
Coming Out Proud, a 3-session program • SSS cant improvement in the more harmful
RCT facilitated by people with mental illness • C ES–D stages of self-stigma (subscales of the
N = 126. to teach adaptive aspects of disclosure, SSMIS, SSS, and CES–D).
pros and cons of disclosure, safer ways to
Intervention group, n = 51 (M age come out, and format of one’s personal The intervention group showed significant
= 46.1). story reductions in harm from pretest to posttest,
F(1, 44) = 6.49, p < .01, and from pretest
Control group, n = 75 (M age = Control to follow-up, F(1, 44) = 3.95, p < .05.
45.2). Wait list, TAU
A significant interaction was found for
Inclusion criteria: None reported; change in applying stereotypes to self
recruitment from mental health cen- across groups, F(2, 98) = 3.74, p < .05.
ters, advocacy groups, and drop-in The intervention group showed a signifi-
centers in California cant reduction in applying stereotypes to
self from pretest to posttest, F(1, 44) =
6.67, p < .05, an effect still evident at
1-mo follow-up, F(1, 42) = 6.98, p < .05.
Çuhadar et al. (2014) Level I Intervention • ISMI ISMI subscale scores for alienation,
Psychoeducation sessions about bipolar • BDFQ approval of stereotypes, social with-
RCT disorder, stigma, and coping skills, 90 drawal, and total internalized stigmatiza-
N = 47 (M age not reported). min/wk for 7 wk tion were significantly reduced for the
intervention group ( p < .001).
Intervention group, n = 24. Control
TAU Perceived discrimination was significantly
Control group, n = 23. reduced for the intervention group
( p < .001) and the control group ( p < .05).
Inclusion criteria: Outpatients diag-
nosed with bipolar disorder in Turkey, A significant correlation was found
aged 18–65, in remission, receiving between internalized stigmatization
outpatient treatment, no problems experienced by participants and BDFQ
with communication subscale scores for participation in social
activities, relationships with friends, tak-
ing initiative, and emotional and mental
functioning.
(Continued)
A126
Fung et al. (2011) Level I Intervention • CSSMIS The intervention reduced self-esteem dec-
Self-stigma reduction program consisting • CAQ–SPMI rement, facilitated readiness for chang-
RCT of 16 sessions (12 group and 4 individ- • PTCS ing own problematic behaviors, and
N = 66. ual) integrating the cyclical framework of • SUMD enhanced psychosocial treatment partici-
affirming personal worth, imagining the pation for individuals with schizophrenia.
Intervention group, n = 34 (M age = future, establishing a sense of control, However, its therapeutic effects were not
43.91). and setting realistic goals to instill hope long lasting and were not maintained
in participants and help them develop after program completion.
Control group, n = 32 (M age =
realistic life goals
46.97). A Group × Time interaction among the
Control two groups showed an overall reduction in
Inclusion criteria: Outpatients in Hong
Newspaper reading group scores on the Self-Esteem Decrement sub-
Kong centers, aged 18–65, DSM–IV
scale of the CCSMIS (p < .05, ES = 0.147).
diagnosis of schizophrenia by a certi-
fied psychiatrist, completed at least A Group × Time interaction showed sig-
primary school, received psychosocial nificant reduction in the stages of change
treatment for past 3 mo before com- continuous score on the CAQ–SPMI (p <
mencement of study .05, ES = 0.122).
A Group × Time interaction showed signifi-

cant reduction in scores on the Participation
subscale of the PTCS (p < 0.5, ES = 0.111).
Lucksted et al. (2011) Level III Intervention • ISMI After ESS, 32% of participants scored
ESS, consisting of lecture, discussion, • MHRM ≥2.5 on the ISMI, compared with 47%
Pretest–posttest sharing of personal experiences, teaching • MSPSS at baseline. Additional exploratory
N = 34 (M age = 54.3). and practice of skills, group support, and • 10 items from the 28-item Boston analysis showed significant (nonadjusted)
problem solving, as well as individualized University Empowerment Scale improvements on all ISMI subscales
Inclusion criteria: Self-reported diag- practice assignments between sessions, except Stigma Resistance.
nosis of schizophrenia, schizoaffective incorporating stigma research, cogni-
disorder, or major mood disorder; ≥1 tive–behavioral therapy, first-person On the MHRM, participants showed
yr of outpatient mental health care; accounts, and empowerment and recov- increases on the Overall Well-Being
willingness to attend all intervention ery approaches, 90 min/wk for 9 wk (p < .05, ES = 0.35), Self-Empowerment
class meetings and interviews; out- (p < .01, ES = 0.83), Learning and Self-
patients using mental health services Control Redefinition (p < .01, ES = 0.58), Basic
at the Baltimore (5 classes) and San None Functioning (p < .01, ES = 0.72), and
Francisco (2 classes) VA Advocacy (p < .01, ES = 0.59) subscales.
MSPSS scores increased significantly (p <

0.5, ES = 0.37).
Mean empowerment scores increased,

but insignificantly (p = .0556 adjusted).
A127
(Continued)
Lysaker et al. (2012) Level II Intervention • ISMI ISMI indexes at baseline and follow-up
Vocational rehabilitation program in • MSEI revealed a modest but significant overall
Quasi-experimental which participants were offered a part- • P ANSS reduction in stigma from 2.36 (SD = .54)
N = 70 (M age = 46.84). time paid work placement within the VA to 2.20 (SD = .57), t = 2.79, p = .007.
medical center; job duties were equiva- Of the 47 participants originally classified
Inclusion criteria: Schizophrenia or lent to entry-level positions, and hospital as having moderate or severe self-stigma
schizoaffective disorder, participa- staff provided supervision. Participants levels, 18 (38%) reported a decrease of
tion in treatment, ability to provide were expected to work 10–20 hr/wk. 25% or more (relative to their baseline
consent; clients at a comprehensive Work placements were matched with stigma index) on the ISMI.
day hospital at a VA medical center participants’ interests and skills when
and a local community mental health possible and could be changed at partici- Analyses revealed a significant group
center, part of a larger survey of the pants’ request. In addition, participants effect for emotional discomfort and self-
effects of cognitive therapy and voca- were offered some form of group and esteem, significant time effects for emo-
tional rehabilitation on people with individual support. tional discomfort and self-esteem, and a
schizophrenia significant Group × Time interaction for
Control self-esteem (MSEI). There was no sig-
None nificant group or time effect for positive
symptoms (PANSS).
McCay et al. (2007) Level I Intervention • PSQ No significant improvement was found
Manualized intervention promoting 5 • MES in measures of self-concept, self-esteem,
RCT goals: (1) developing a personally accept- • Tennessee Self-Concept Scale self-efficacy, or stigma.
N = 47. able interpretation of the illness experi- • QLS
ence; (2) minimizing self-stigmatizing • MHS A repeated measures ANOVA revealed
Intervention group, n = 29 (M age = attitudes; (3) reducing engulfment; (4) • RSES a significant Group × Time effect on
25.07). developing a sense of future, hopes, and • Self-Efficacy Scale measures of engulfment, quality of life,
dreams; and (5) developing and pursuing and hope. Post hoc t tests revealed that
Control group, n = 18 (M age = 26.17). the treatment group reported significant
meaningful life goals set by each partici-
improvements in engulfment, quality of
Inclusion criteria: Mental health clinic pant, 1.5 hr/wk for 12 wk
life, and hope measures. No significant
clients in Toronto; aged 18–35;
Control changes were observed in these variables
DSM–IV diagnosis of schizophrenia,
TAU for the control group.
schizophreniform disorder, or schizoaf-
fective disorder; no previous psychiat- The intervention group showed signifi-
ric hospitalizations; no antipsychotic cant decreases in MES, QLS, and MHS
medications for >8 wk before study; scores compared with the control group
within 2 yr of initial treatment for (p < .05).
first episode of schizophrenia; able to
The other outcome measures yielded no
read, comprehend, and speak English;

able to give informed consent significant findings.
A128
(Continued)
Mittal et al. (2012) Level I Intervention • ISMI 8 studies reported significant decreases in
The most common intervention strategy • PDDS self-stigma levels postintervention. Only
Systematic review was psychoeducation alone or combined • PSQ 2 of the 7 studies involving patients with
N = 14 studies. with cognitive restructuring, most often • Self-Stigma of Seeking Help Scale schizophrenia or a psychotic disorder
conducted in a group format. The number • Depression Stigma Scale reported significant improvement.
N = 88–2,297 participants (range of of educational sessions ranged from 1 • CSSMIS
sample sizes). to 23. Effect sizes (Cohen’s d) were mostly small
(0.20) to medium (0.50). Large effect
Inclusion criteria: Articles described or Control sizes, 8.03 and .95, were reported in only
cited in an accessible source, interven- NA 2 studies. Because most of these studies
tion targeting self-stigma as a primary were RCTs with small sample sizes, effect
or secondary outcome, participants sizes should be interpreted with caution.
with psychiatric illness (e.g., schizo-
phrenia, bipolar disorder, substance Most of the studies reviewed were
use disorder, depression, posttraumatic exploratory or pilot investigations with
stress disorder) or in a high-risk group significant limitations, such as small
(e.g., exposure to traumatic life event), sample size, lack of randomization, or no
quantitative data analysis using accept- control group.
able statistical tools to determine effec-
tiveness of interventions; participants
were predominantly diagnosed with
schizophrenia, depression, or substance
use or were at-risk combat veterans
Morrison et al. (2013) Level I Intervention • PBEQ Negative appraisal scores on the PBEQ
Cognitive therapy including development • CAARMS were significantly lower at 12 mo in
RCT of a problem and goal list, early formula- the intervention group (95% CI [72.69,
N = 288 (M age = 20.74 ± 4.34). tion (both longitudinal and maintenance), 70.02], p = .047).
a focus on normalizing psychotic-like
Intervention group, n = 144. experiences, and an active therapy stance No significant difference was found
using behavioral experiments and evalu- between groups in social acceptability
Control group, n = 144. scores (coefficient = .46, 95% CI [70.05,
ation of appraisals; 26 weekly sessions
plus up to 4 booster sessions in subse- 0.98], p = .079). Social acceptability
Inclusion criteria: Help-seeking
quent 6 mo; in addition to TAU, monitor- showed a small increase over time that
patients aged 14–35 in primary and
ing, and CAARMS assessment did not reach significance (coefficient =
secondary care settings in England
.06, 95% CI [0.00, 0.12], p = .051).
experiencing brief limited intermittent
Control
psychotic symptoms, attenuated psy-
TAU plus monitoring
chotic symptoms, or state-plus-trait
factors
A129
(Continued)
Roe et al. (2014) Level II Intervention • ISMI A significant Group × Time interaction
NECT, a structured group-based inter- • MANSA for the internalized stigma variable was
Case-control, nonrandom assign- vention for people with SMI aimed at • ADHS found, F(4, 114) = 2.68, p < .04, η2 p =
ment, concurrent controls reducing self-stigma, delivered by mental • RSES .09. A significant difference was found
N = 119. health professionals (social workers, between groups in mean change in self-
occupational therapists, and psycholo- stigma score between Time 1 and Time 2.
Intervention group, n = 63 (M age gists) who were employed by the psychi- Improvement in self-stigma was signifi-
= 39). atric rehabilitation centers, experienced cantly higher for the intervention group.
in providing psychiatric rehabilitation ser-
Control group, n = 56 (M age = 44). Total ISMI scores were not significantly
vices, and trained in NECT, in addition to
different between groups over time,
Inclusion criteria: Clients in psychiat- existing services, 20 1-hr weekly sessions
but scores on the Alienation and Social
ric rehabilitation centers in Israel who over approximately 6 mo
Withdrawal (p < .01) and Discrimination
met Israeli criteria for “psychiatric
Control Experience (p < .05) subscales were
disability” severe enough to com-
TAU significantly lower for the intervention
promise at least 40% of functioning
group.
(roughly comparable to U.S. designa-
tion of SMI) MANSA and ADHS scores showed signifi-
cant differences favoring the intervention
group (p < .05).
Rüsch et al. (2014) Level I Intervention • ISMI No significant effect of the intervention
Coming Out Proud, a manualized group • SSS on the primary measure of internalized
RCT intervention consisting of 3 lessons • Empowerment Scale stigma or the secondary measure of
N = 100 (M age = 41.95). to support people with mental illness • Link’s Secrecy Scale empowerment was found. However,
in decisions regarding disclosure and • Stigma Coping Orientation Scale the intervention had significant posi-
Intervention group, n = 50. secrecy in different settings, 2-hr weekly • Coming Out With Mental Illness Scale tive effects on the cognitive appraisal of
sessions for 3 wk stigma as a stressor, disclosure-related
distress, perceived benefits of disclosure,
Control and secrecy.
Inclusion criteria: People with mental
TAU
illness in Switzerland with ≥1 self-
SSS scores differed significantly between
reported current DSM–IV Axis I or
groups at both time points (p < .01).
Axis II disorder, aged ≥18, sufficient
German language skills, and at least No other outcome measures yielded sig-
a moderate level of self-reported nificant findings.
disclosure-related distress
(Continued)
A130
Russinova et al. (2014) Level I Intervention • Approaches to Coping With Stigma ISMI scores were significantly improved
Manualized (workbook and leader’s Scales at 3-mo follow-up for the intervention
RCT guide) peer-led intervention to reduce • ISMI group (p = .03, ES [Cohen’s d] = 0.55).
N = 82 (M age not reported). stigma integrating PhotoVoice methodol- • CES–D
ogy with psychoeducation about stigma • Empowerment Scale Participation in the intervention was
Intervention group, n = 40. and experiential exercises to reduce • Generalized Perceived Self-Efficacy associated with significantly greater
endorsement of stereotypes about mental Scale reductions in self-stigma and greater
Control group, n = 42. increases in proactive coping with per-
illness, weekly 90-min group sessions
ceived stigma and in sense of community
Inclusion criteria: Patients in a univer- over 10 wk
activism.
sity-based psychosocial rehabilitation
Control
program, aged ≥18, DSM–IV Axis I or
Wait list, TAU No differences were found between
Axis II diagnosis, marked functional groups in depression, self-efficacy,
impairment in social or occupational or other subscales of the internalized
roles stigma, coping with stigma, and empow-
erment measures.
Sibitz et al. (2013) Level I Intervention • ISMI ISMI total (p < .05) and Alienation sub-
Recovery-oriented day program providing • PANSS scale (p < .01) scores showed a signifi-
RCT (allocation based on mean wait- multiple therapeutic, mostly group-based, • W HOQOL–BREF cant Group × Time interaction indicating
ing time to start intervention group) structured activities including psycho- a difference between groups in change
N = 80. education, living skills, and occupational over time (ES [Cohen’s d] = 0.725).
therapy, 8:30–3:30, 5 days/wk for 2 mo
Intervention group, n = 40 (M age Significant group effects (p < .01) for the
= 31.7). Control ISMI Discrimination Experience and Social
Wait list, TAU Withdrawal subscales indicate higher
Control group, n = 40 (M age = internalized stigma in the control group
32.4). at both time points, as well as for ISMI
total score at follow-up.
Inclusion criteria: Clients of an outpa-
tient clinic in Germany, aged 18–65, PANSS scores showed a significant Group
ICD–10 diagnosis of schizophrenia × Time interaction (p < .05) indicating a
spectrum disorder, motivated to reduction in symptoms for the interven-
attend the day clinic tion group at follow-up.
For the WHOQOL–BREF, a significant

Group × Time interaction (p < .01)
was found only on the Psychological
Health subscale at follow-up, indicating
improved psychological health.
(Continued)
A131
Silverman (2013) Level I Intervention SSS The intervention group showed signifi-
Group songwriting intervention in which cant differences in measures of disclo-
Cluster randomized single-session participants compose lyrics for “The sure, discrimination, and total stigma
3-group design Stigma Blues” compared with Control Group 2 (p < .05)
N = 78 (M age = 35.88–38.65). but no differences compared with Control
Control Group 1.
Intervention group, n = 29. Group 1: Education only
Control Group 1, n = 17. Group 2: Wait list
Inclusion criteria: Acute care psychiat-

ric inpatients in the U.S. Midwest
Staring et al. (2013) Level III Intervention • PANSS negative syndrome A large effect size (Cohen’s d = .95) was
Manualized CBT for negative symptoms • ISMI found on the measure of dysfunctional
Open trial pilot, pretest–posttest intervention based on the work of Grant • BDI beliefs, which included measures from
N = 21 (M age = 40.6). and colleagues, up to 20 sessions • BHS the ISMI.
• Dysfunctional Attitudes Scale–
Inclusion criteria: Outpatients from Control Defeatist Performance Attitude Improvement on the primary outcome
nine psychiatric institutions in the None measure (PANSS) was highly significant
Netherlands, chart diagnosis of and clinically relevant (p = .001), indicat-
schizophrenia spectrum disorder, ing that participants’ negative thoughts
≥3 PANSS negative syndrome items and expectations related to functioning
scoring ≥3 about which the patient were improved.
expressed dissatisfaction for a total This analysis showed that the change in
negative score ≥13 negative symptoms was not explained by
a change in depression scores because
the effects of depression in the regression
analysis were nonsignificant (t = 1.07,
p = .291) and the changes achieved
during the treatment period remained
significant.
(Continued)
A132
Tsang et al. (2016) Level I Intervention • ISMI Nine studies reported significant internal-
Interventions to reduce internalized • SSMIS ized stigma reduction as measured by the
Systematic review and meta-analysis stigma in people with SMI. Most pro- • CSSMIS ISMI, SSMIS, CSSMIS, and PSQ.
N = 14 studies (5 included in grams adopted a psychoeducation • PSQ
approach in combination with other Total ISMI scores from 3 psychosocial
meta-analysis). interventions were pooled, and the
components such as CBT, social skills
N = 1,331 participants (879 in training, goal attainment, and narrative pooled SMD was –.43 (CI [−0.72,
intervention groups, 452 in control therapy. The programs ranged from 10 to −0.14]), indicating a small to moder-
groups; sample range = 21–205). 40 sessions. Some were peer-led group ate effect (p = .003) of psychosocial
discussions on the topics of secrecy and interventions.
Inclusion criteria: RCTs, clinical trials,
disclosure. The meta-analysis showed a moderate
and experimental studies studying
interventions to reduce internalized Control significant effect of professional-led
stigma in people with SMI, operation- NA intervention (SMD = −0.51, CI [−0.79,
ally defined as mental illness having −0.23], p = .001) but not peer-led
a chronic course and leading to intervention.
significant social and occupational
dysfunction
Uchino et al. (2012) Level II Intervention • SDS Japanese version Significant differences between groups
Manualized psychoeducation group • KIDI were found in SDS, KIDI, DAI–10, and
2 groups, nonrandomized meetings focused on reducing self- • DAI–10 BPIS scores, and thus these instruments
N = 56 (M age = 34.2). stigma, weekly sessions over 6 wk • BPIS were selected as objective variables
• GAF for path analysis. GAF scores were not
Intervention group, n = 29. Control significantly different between groups,
TAU but this measure was included in the
path analysis because GAF was the
Inclusion criteria: Hospital patients only variable that showed participants’
in Japan with a DSM–IV diagnosis pathological condition.
of schizophrenia or schizoaffective
disorder
(Continued)
A133
Path analysis results show that

increasing knowledge about mental
disorders and treatment, particularly
for people with schizophrenia, might
play an important role in reducing
the self-stigma associated with these
disorders. This result indicates that
psychoeducation can reduce social dis-
tance for people with mental disorders
by increasing their knowledge about
their disease.

cantly improved scores compared with
the control group (p < .05).
No other outcome measures yielded sig-

nificant findings.
Yanos et al. (2012) Level I Intervention • ISMI No significant between-group differences

NECT, a structured group-based interven- • BHS or trends were evident. Findings did not
RCT tion for people with SMI aimed at reduc- • RSES support the hypothesis that NECT is more
N = 39. ing self-stigma (see Yanos et al., 2011), • CSC effective than TAU in leading to signifi-
facilitated by 2 clinicians, 20 sessions • QLS cant improvements in internalized stigma
Intervention group, n = 21 (M age = • PANSS and related outcomes over time.
47.14). Control
TAU
(Continued)
A134
Control group, n = 18 (M age = No significant differences in ISMI, BHS,

48.06). RSES, or CSC scores were found at 3-mo
follow-up.
Inclusion criteria: Clients of Assertive
Community Treatment teams in
New York City and partial care in
a VA hospital in Indiana; elevated
internalized stigma; DSM–5 diag-
nosis of schizophrenia, schizoaf-
fective disorder, or bipolar disorder
or major depression determined by
the Structured Clinical Interview for
DSM–IV
Note. Participant ages are expressed in years unless otherwise noted. ADHS = Adult Dispositional Hope Scale; ANOVA = analysis of variance; BDFQ = Bipolar Disorder Functioning Questionnaire; BDI = Beck Depression
Inventory; BHS = Beck Hopelessness Scale; BPIS = Birchwood’s Psychosis Insight Scale; CAARMS = Comprehensive Assessment of At-Risk Mental States; CAQ–SPMI = Change Assessment Questionnaire for People
With Severe and Persistent Mental Illness; CBT = cognitive–behavioral therapy; CES–D = Center for Epidemiological Studies Depression Scale; CI = confidence interval; CSC = Coping With Symptoms Checklist; CSSMIS
= Chinese Self-Stigma of Mental Illness Scale; DAI = Drug Attitude Inventory; DSM = Diagnostic and Statistical Manual of Mental Disorders; ES = effect size; ESS = Ending Self-Stigma; GAF = Global Assessment of
Functioning; ICD = International Statistical Classification of Diseases and Related Health Problems; ISMI = Internalized Stigma of Mental Illness Scale; KASQ = Knowledge About Schizophrenia Questionnaire; KIDI =
Knowledge of Illness and Drugs Inventory; M = mean; MANSA = Manchester Short Assessment of Quality of Life; MES = Modified Engulfment Scale; MHRM = Mental Health Recovery Measure; MHS = Miller Hope Scale;
MSEI = Multidimensional Self-Esteem Inventory; MSPSS = Multidimensional Scale of Perceived Social Support; NA = not applicable; NECT = Narrative Enhancement and Cognitive Therapy; PANSS = Positive and Negative
Syndrome Scale; PBEQ = Personal Beliefs about Experiences Questionnaire; PDDS = Perceived Devaluation–Discrimination Scale; PSQ = Perceived Stigma Questionnaire; PTCS = Psychosocial Treatment Compliance Scale;
QLS = Quality of Life Scale; RCT = randomized controlled trial; RSES = Rosenberg Self-Esteem Scale; SD = standard deviation; SDS = Social Distance Scale; SMD = standard mean difference; SMI = serious mental ill-
ness; SSMIS = Self-Stigma of Mental Illness Scale; SSS = Stigma Stress Scale; SUMD = Scale to Assess Unawareness in Mental Disorder; TAU = treatment as usual; VA = Veterans Affairs; WHOQOL–BREF = World Health
Organization Quality of Life Brief scale.
Source. Swarbrick, M. (2018). Critically Appraised Topic—What is the evidence for the effectiveness of interventions to reduce internalized stigma (self-stigma) for people with serious mental illness? Retrieved from
http://www.aota.org/∼/media/Corporate/Files/Secure/Practice/CCL/Mental%20Health/MiniCAT_MH_Stigma.pdf
A135
Table A.14. Risk-of-Bias Analysis for Intervention Studies Included in the Systematic Review of Interventions to Reduce Internalized Stigma for Adults Living
With SMI

Selection Bias (Attrition Bias)
Blinding of Blinding of Selective
Random Participants Outcome Reporting
Sequence Allocation and Personnel Assessment Short Term Long Term (Reporting
Aho-Mustonen et al. (2011) + ? – + + + +
Conner et al. (2015) – + + + + + +
Corrigan et al. (2015) + ? + ? + + +
Çuhadar et al. (2014) + – – – + – +
Fung et al. (2011) + + + + + + +
Lucksted et al. (2011) – – + + + + +
Lysaker et al. (2012) – – + ? + + +
McCay et al. (2007) + ? – + + – +
Morrison et al. (2013) + + + + + + +
Roe et al. (2014) – – + + + – +
Rüsch et al. (2014) + + – + + + +
Russinova et al. (2014) + + – ? + + +
Sibitz et al. (2013) + – – + + + +
Silverman (2013) + + – – + + +
Staring et al. (2013) – + – – + + –
(Continued)
A136
Table A.14. Risk-of-Bias Analysis for Intervention Studies Included in the Systematic Review of Interventions to Reduce Internalized Stigma for Adults Living
With SMI (cont.)

Selection Bias (Attrition Bias)
Blinding of Blinding of Selective
Random Participants Outcome Reporting
Sequence Allocation and Personnel Assessment Short Term Long Term (Reporting
Uchino et al. (2012) – – + – – – –
Yanos et al. (2012) + + + ? + + +
Risk-of-bias table format adapted from “Assessing Risk of Bias in Included Studies,” by J. P. T. Higgins, D. G. Altman, and J. A. C. Sterne, in Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0), by J. P. T.
Higgins and S. Green (Eds.), 2011, London: Cochrane Collaboration. Retrieved from http://handbook-5-1.cochrane.org. Copyright © 2011 by The Cochrane Collaboration.
A137
Table A.15. Risk-of-Bias Analysis for Systematic Reviews Included in the Systematic Review of Interventions to Reduce Internalized Stigma for Adults Living
With SMI
Duplicate Comprehensive Status of List of Included/ Characteristics Quality Quality Methods Used Likelihood of Conflict
A Priori Study Literature Publication Excluded of Included of Studies Assessment to Combine Publication of
Design Selection/Data Search as Inclusion Studies Studies Assessed and Used Results Bias Interest
Citation Included? Extraction? Performed? Criteria? Provided? Provided? Documented? Appropriately? Appropriate? Assessed? Stated?
Mittal et al. (2012) + + + + + + + + + – +
Tsang et al. (2016) + + + + + + + + + – +
Note. Categories for risk of bias are as follows: + = low risk of bias; – = high risk of bias.
Hamel, . . . L. M. Bouter, 2007, BMC Medical Research Methodology, 7, p. 10. https:/doi.org/10.1186/1471-2288-7-10
A138

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T h e A O TA P r a c t i c e G u i d e l i n e s S e r i e s

Occupational Therapy Practice Guidelines for

Adults Living With

Occupational Therapy Practice Guidelines for

Adults Living With

Susan Noyes, PhD, OTR/L

Elizabeth Griffin Lannigan, PhD,

Caroline Polk, Digital Manager and AJOT Managing Editor

Rebecca Rutberg, Director, Marketing

The American Occupational Therapy Association, Inc.

© 2019 by the American Occupational Therapy Association, Inc.

ISBN-13: 978-1-56900-594-1 (ebook)

Cover design by Jennifer Folden

Abbreviations and Acronyms Used in This Publication������������������������������������������������������������xvi

Chapter 1. Overview of Serious Mental Illness��������������������������������������������������������������������������� 1

Chapter 2. Systematic Review Methodology and Overview of Findings������������������������������������� 8

Chapter 4. Evidence for Interventions to Support Employment and Education������������������������� 17

Chapter 5. Evidence for Interventions to Promote Health and Wellness����������������������������������� 22

Chapter 7. Evidence for Interventions to Reduce Internalized Stigma��������������������������������������� 34

Boxes and Tables

Table 7.1. Levels of Evidence for Interventions to Reduce Internalized Stigma���������������������� 34

• T o assist occupational therapy researchers in this practice area in determining outcome

Practice Guidelines Overview

information on the effectiveness of occupational therapy interventions to support functioning

Summary of Key Findings

Skills Training Interventions.

Interventions to Support Employment and Education

Interventions to Promote Health and Wellness

Interventions to Reduce Internalized Stigma

Implications for Practice, Education, and Research

Clinical Recommendations for Occupational Therapy Practice

CAT Cognitive Adaptation Training

EIS early intervention services

ISE integrated supported employment

NEAR Neuropsychological Educational Approach to Remediation

SAI State Anxiety Inventory

STAI State–Trait Anxiety Inventory

Serious Mental Illness

Mental Disorders Considered SMI

Schizophrenia Spectrum Disorders

EF lead to significant cognitive impairment in up to 75% of persons living with schizophrenia

Major Depressive Disorders

Co-­occurrence and Other Considerations

These interwoven barriers to successful occupational engagement in community living for

Occupational Therapy Perspectives for Individuals Living With SMI

Key Components of the Recovery Perspective

Occupational Therapy’s Link to Recovery Perspectives

Table 2.1. Levels of Evidence

Level Study Designs

Level II Two groups, nonrandomized studies (e.g., cohort, case-­control)

Note. RCTs = randomized controlled trials.

Inclusion and Exclusion Criteria

Categories Key Search Terms

Overview of Search Results

Type of Intervention I II III IV V Totals

ADLs and IADLs, rest and sleep, leisure, and

Employment and education 47 8 1 1 0 57

Health and wellness 85 0 0 0 0 85

Totals 224 19 9 1 0 253

Table 2.4. Strength of Evidence

Strong Consistent evidence from at least 2 well-­designed, high-­quality RCTs

Mixed Inconsistent findings across studies

Note. RCTs = randomized controlled trials.

Abbreviations and Acronyms Used in This Publication��xvi

Chapter 1. Overview of Serious Mental Illness�� 1

Chapter 2. Systematic Review Methodology and Overview of Findings�� 8

Chapter 4. Evidence for Interventions to Support Employment and Education�� 17

Chapter 5. Evidence for Interventions to Promote Health and Wellness�� 22

Chapter 7. Evidence for Interventions to Reduce Internalized Stigma�� 34

Table 7.1. Levels of Evidence for Interventions to Reduce Internalized Stigma�� 34

• T o assist occupational therapy researchers in this practice area in determining outcome

Co-occurrence and Other Considerations

Table 2.1. Levels of Evidence

Level II Two groups, nonrandomized studies (e.g., cohort, case-control)

Table 2.4. Strength of Evidence

Strong Consistent evidence from at least 2 well-designed, high-quality RCTs

I Systematic reviews and meta-analyses 11

II Two groups, nonrandomized studies (cohort, case-control) 6

Table 4.1. Levels of Evidence for Interventions to Support Employment and Education

I Systematic reviews and meta-analyses 8

Table 5.1. Levels of Evidence for Interventions to Promote Health and Wellness

I Systematic reviews and meta-analyses 21

Table 5.2. Levels of Evidence for Health and Wellness Interventions, by Theme

Level I systematic reviews and meta-analyses 6 4 9 2

I Systematic reviews and meta-analyses 22

II Two groups, nonrandomized studies (cohort, case-control) 2

Table 7.1. Levels of Evidence for Interventions to Reduce Internalized Stigma

I Systematic reviews and meta-analyses 2

Table 7.2. Levels of Evidence for Internalized Stigma Interventions, by Theme

Box 10.1. Case Study 1. Pete—Early Intervention, Employment, and Internalized Stigma