BackgroundCognitive Behavioral Social Skills Training (CBSST) is a targeted psychological intervention designed to improve daily functioning and to address negative symptoms in individuals diagnosed with schizophrenia. Despite evidence from clinical trials suggesting beneficial effects of CBSST on functioning and negative symptoms, the overall efficacy of CBSST remains to be quantified. Furthermore, potential moderators and mediators of treatment outcomes remain elusive. This protocol outlines an individual participant data meta-analysis (IPD-MA) with the objective to examine the efficacy of CBSST on psychosocial functioning in schizophrenia.MethodIn accordance with the Preferred Reporting Items for a Systematic review and Meta-Analysis of Individual Participant Data (PRISMA-IPD) guidelines, we will conduct a systematic literature search and employ two-stage and one-stage meta-analytical approaches. The meta-analytical models will evaluate the overall effect of CBSST relative to control treatments in randomized-control trials, identify participant-level (e.g., age, cognitive impairment) and study-level (e.g., individual vs. group settings) predictors of change, and explore the mechanisms that mediate improvement in functioning, such as skills acquisition and cognitive restructuring of defeatist attitudes. Furthermore, the analysis will attempt to determine the optimal amount of CBSST sessions required to enhance functioning and evaluate the impact of patient-level factors driving delivered dosage.DiscussionThe objective of this study is to contribute to the existing literature by addressing the current gaps in understanding the efficacy of CBSST and identifying critical factors for treatment success. Our findings will have the potential to inform personalized treatment planning and the development of clinical guideline recommendations focusing on functional outcomes and negative symptoms in people with schizophrenia.Systematic review registrationPROSPERO CRD42024605353.

Background Clinical trials of cognitive-behavioral therapy (CBT) for negative symptoms of schizophrenia have provided mixed results, perhaps because some patients are more likely to benefit than others. Patients likely to benefit may be those with greater pre-treatment motivation. To better examine the effects of motivation on treatment outcome, more objective measures of motivation are needed. Pupillary responses provide an objective biomarker of cognitive effort and motivation, with greater dilation associated with greater effort and motivation. Aims The current study examined whether pre-treatment baseline pupil dilation predicted motivation and pleasure (MAP) negative symptom reduction in an open clinical trial of CBT for individuals with schizophrenia. Methods Pupil dilation was recorded during the digit-span task at low (3 digits), moderate (6 digits) and high (9 digits) loads in participants with schizophrenia or schizoaffective disorder (N = 31) with persistent negative symptoms prior to delivery of mobile-assisted CBT for negative symptoms (mCBTn). Results Greater pre-treatment pupil dilation during low, but not moderate or high, loads of the digit-span task significantly predicted greater reduction in MAP negative symptoms. However, while MAP negative symptoms improved throughout treatment, pupil dilation did not significantly change throughout treatment for any digit-span loads. Implications Pupil dilation may provide a much-needed prognostic biomarker of patients most likely to benefit from CBT for MAP symptoms, but did not change with change in MAP symptoms.

Objective:We examined the use of pupillometry as an early risk marker of Alzheimer's disease (AD). Pupil dilation during a cognitive task has been shown to be an index of cognitive effort and may provide a marker of early change in cognition even before performance begins to decline. Individuals who require more effort to successfully perform a task may be closer to decline. We previously found greater compensatory effort to perform the digit span task in individuals with amnestic mild cognitive impairment (aMCI) who may be at greater risk for AD than individuals with non-amnestic MCI (naMCI). Task evoked pupil dilation is linked to increased norepinephrine output from the locus coeruleus (LC), a structure affected early in the AD pathological process. In this study, we measured pupil dilation during verbal fluency tasks in participants with aMCI or naMCI, and cognitively normal (CN) individuals. Based on our findings using the digit span task, we hypothesized that participants with aMCI would show greater compensatory cognitive effort than the other two groups.Participants and Methods:This study included 101 older adults without dementia recruited from the UC San Diego Shiley-Marcos Alzheimer's Disease Research Center and San Diego community (mean [SD] age = 74.7 [5.8]; education = 16.6 [2.5]; N=58 female; N=92 White); 62 CN, 20 aMCI and 19 naMCI participants. Pupillary responses (change relative to baseline at the start of each trial) were recorded at 30 Hz using a Tobii X2-30 (Tobii, Stockholm, Sweden) during semantic (animals, fruits, vegetables) and phonemic (letters F, A, S) fluency tasks. Participants generated as many words as possible in a category (semantic) or starting with a given letter (phonemic) in 60 seconds.Results:Repeated measures ANOVA (3 groups X 2 fluency conditions) with age, education and sex as covariates showed a significant main effect of group (F(2,95)=3.64, p=.03), but no group X condition interaction (F<1). Pairwise comparisons showed significantly greater fluency task-evoked dilation for aMCI relative to CN (p=.015) and naMCI (p=.019) participants. When controlling for performance (total letter or category words produced), pupil dilation (cognitive effort) remained significantly greater in aMCI relative to the other two groups in both fluency conditions, suggesting pupil dilation informs risk beyond information provided by task performance.Conclusions:In a previous sample of community-dwelling men who were an average of 13 years younger than the present sample, we found significantly greater pupil dilation during a digit span task in aMCI relative to naMCI and CN groups. In the present study, we replicated those findings in an older sample using a different cognitive task. Significantly greater pupil dilation was found in individuals with aMCI on verbal fluency tasks, indicating greater compensatory cognitive effort to maintain performance. Pupillometry provides a promising biomarker that might be used as an inexpensive and noninvasive additional screening tool for risk of AD.

We examined pupillary responses as a novel biomarker of early risk for Alzheimer’s disease (AD). Pupil dilation recorded during cognitive tasks provides a biomarker of the extent of cognitive effort required to achieve a given test score. Greater dilation indicates greater effort. Test scores decline when capacity to compensate is exceeded, so individuals allocating more effort are likely closer to maximum compensatory capacity and at higher risk for decline. We previously found greater pupil dilation in individuals with mild cognitive impairment (MCI) relative to cognitively‐normal (CN) controls. Pupillary responses reflect neuromodulatory activity in the locus coeruleus (LC), and studies implicate the LC as an early site of AD degenerative changes, especially tauopathy. The present study, therefore, examined whether greater pupil dilation (compensatory cognitive effort) on the digit span task was associated with greater tau biomarker levels.

Background Negative symptoms are an important unmet treatment need for schizophrenia. This study is a preliminary, open, single-arm trial of a novel hybrid intervention called mobile-assisted cognitive behavioral therapy for negative symptoms (mCBTn). Objective The primary aim was to test whether mCBTn was feasible and could reduce severity of the target mechanism, defeatist performance attitudes, which are associated with experiential negative symptoms and poor functioning in schizophrenia. Methods Participants with schizophrenia or schizoaffective disorder (N=31) who met prospective criteria for persistent negative symptoms were enrolled. The blended intervention combines weekly in-person group therapy with a smartphone app called CBT2go. The app extended therapy group skills, including recovery goal setting, thought challenging, scheduling of pleasurable activities and social interactions, and pleasure-savoring interventions to modify defeatist attitudes and improve experiential negative symptoms. Results Retention was excellent (87% at 18 weeks), and severity of defeatist attitudes and experiential negative symptoms declined significantly in the mCBTn intervention with large effect sizes. Conclusions The findings suggest that mCBTn is a feasible and potentially effective treatment for experiential negative symptoms, if confirmed in a larger randomized controlled trial. The findings also provide support for the defeatist attitude model of experiential negative symptoms and suggest that blended technology-supported interventions such as mCBTn can strengthen and shorten intensive psychosocial interventions for schizophrenia. Trial Registration ClinicalTrials.gov NCT03179696; https://clinicaltrials.gov/ct2/show/NCT03179696

Psychosocial rehabilitation interventions are needed to improve functioning in people with schizophrenia, particularly for older adults. In multiple clinical trials, cognitive-behavioral social skills training (CBSST) has been found to improve community functioning in younger and older participants with schizophrenia. To reduce the burden and possibly strengthen CBSST, we developed a mobile-assisted CBSST intervention (MA-CBSST), in which therapist contact was reduced 50% and group sessions were supplemented by a mobile device that prompted at-home practice of CBSST skills. This study was a preliminary randomized clinical trial comparing: (1) the full CBSST program; (2) MA-CBSST and (3) a device contact (DC) control (only symptom and activity monitoring) in 57 older adults with schizophrenia (age>45). Relative to DC-only, CBSST skill knowledge and self-reported functioning improved significantly more in the full CBSST program and full CBSST and MA-CBSST groups did not differ significantly, but improvements on these outcomes were only marginally significant for MA-CBSST relative to DC-only with smaller effect sizes. The results replicated multiple prior clinical trials showing improvement in functioning in schizophrenia in CBSST, but the effect of MA-CBSST on functioning was weaker than the full CBSST program.

Schizophrenia is a debilitating mental disorder that is associated with cognitive deficits. Impairments in cognition occur early in the course of illness and are associated with poor functional outcome, but have been difficult to treat with conventional treatments. Recent studies have implicated abnormal neural network dynamics and impaired connectivity in frontal brain regions as possible causes of cognitive deficits. For example, high-frequency, dorsal-lateral prefrontal oscillatory activity in the gamma range (30–50 Hz) is associated with impaired working memory in individuals with schizophrenia. In light of these findings, it may be possible to use EEG neurofeedback (EEG-NFB) to train individuals with schizophrenia to enhance frontal gamma activity to improve working memory and cognition. In a single-group, proof-of-concept study, 31 individuals with schizophrenia received 12 weeks of twice weekly EEG-NFB to enhance frontal gamma band response. EEG-NFB was well-tolerated, associated with increased gamma training threshold, and significant increases in frontal gamma power during an n-back working memory task. Additionally, EEG-NFB was associated with significant improvements in n-back performance and working memory, speed of processing, and reasoning and problem solving on neuropsychological tests. Change in gamma power was associated with change in cognition. Significant improvements in psychiatric symptoms were also found. These encouraging findings suggest EEG-NFB targeting frontal gamma activity may provide a novel effective approach to cognitive remediation in schizophrenia, although placebo-controlled trials are needed to assess the effects of non-treatment related factors.

A pilot study of Veterans with serious mental illness assessed fidelity and preliminary outcomes of peer specialist (PS)-delivered Cognitive-Behavioral Social Skills Training (CBSST). A single-arm, baseline-post pilot involved 4 PSs and 12 Veterans, split between two sites. Five functioning and symptom measures were administered before and after the 12-week intervention. Half of all sessions were rated on a standardized fidelity measure. Four outcomes (symptoms, hope, defeatist attitudes, skill learning) showed statistically significant improvement. Effect sizes and fidelity ratings matched previous trials with the training, and the fidelity ratings exceeded the threshold for competence. Although more research is needed, PSs could improve services for serious mental illness by delivering structured interventions.

The generic cognitive model (CBT) can be applied to the treatment of negative symptoms in schizophrenia. Defeatist attitudes (e.g., “Why bother trying, I always fail”) contribute to amotivation and asociality and ultimately poor functioning in schizophrenia. Prior CBT clinical trials targeting defeatist attitudes have found that improvement in defeatist attitudes is associated with improvement in negative symptoms in schizophrenia. Using an experimental therapeutics approach (R61/R33), we tested a novel intervention for negative symptoms in schizophrenia called, Mobile-assisted CBT for Negative symptoms (mCBTn). mCBTn is an integration of CBT-informed components targeting defeatist attitudes from our Cognitive-Behavioral Social Skills Training (CBSST) group therapy and mobile smartphone interventions (“CBT2go” app) from our prior clinical trials research. We report here on the R61 phase, which was an open trial of mCBTn in 31 participants with schizophrenia with persistent moderate-to-severe negative symptoms. Weekly 90-min sessions of group CBT plus the CBT2go iPhone app targeted defeatist attitudes, pleasure savoring, and behavioral activation/goal setting. The primary aim was to test whether mCBTn can reduce severity of the treatment target: defeatist performance attitudes. We recruited and assessed 67 participants; however, only 31 participants started the intervention, because 36 (54%) of participants did not meet the strict persistent negative symptoms entry criteria. After starting treatment, however, retention rates were excellent, especially for this negative symptom population: 87%, 84% and 79% at the 12-, 18- and 24-week assessments, respectively. Significant improvements were found on the Defeatist Performance Attitudes Scale with medium to large effect sizes (DPAS; Week 12 d=.4, p=.034; Week 18 d=.7, p<.001; Week 24 d=.9, p=.002). Negative symptoms (CAINS Motivation and Pleasure) also showed significant reduction with large effect sizes at all assessment points (Week 12 d=.6, p=.048; Week 18 d=.8, p=.007; Week 24, d=.7, p=.014), and positive symptoms also showed significant reduction by week 24 (p=.014, d=.5). The large effect sizes for DPAS and CAINS MAP by week 18 suggest an 18-week intervention might be sufficient to produce meaningful improvements, which is faster than in our prior CBSST trials of group therapy alone. This preliminary open trial of mCBTn suggests that mobile apps can strengthen psychotherapy and targeting defeatist attitudes in participants with schizophrenia with persistent negative symptoms can lead to improvement in motivation and pleasure negative symptoms.

Schizophrenia is a major cause of disability worldwide. As new treatments for functioning are tested, the need grows to demonstrate real-world functioning gains. Ecological momentary assessment (EMA) may provide a more ecologically valid measure of functioning. In this study, smartphone-based EMA was used to signal participants with schizophrenia (N = 100) and controls (N = 71) 7 times a day for 7 days to respond to brief questionnaires about social interactions and functioning behaviors. Excellent adherence was found, with both groups completing an average of 85% of surveys and only 3% of participants with schizophrenia excluded for poor adherence. Four-week test-retest reliability was high (r = .83 for total productive behaviors). Relative to controls, participants with schizophrenia reported significantly less total productive activity (d = 1.2), fewer social interactions (d = 0.3), more nonproductive behaviors (d = 1.0; watching TV, resting), and more time at home (d = 0.8). Within the schizophrenia group, participants living independently showed better functioning on EMA relative to participants in supported housing (d = 0.8) and participants engaged in vocational activities showed better functioning than individuals not engaged in vocational activities (d = 0.55). Modest correlations were found between EMA and an in-lab self-report measure of functioning activities performed in the community, but not between EMA and measures of functional capacity or potential. This study demonstrated the feasibility, sensitivity reliability, and validity of EMA methods to assess functioning in schizophrenia. EMA provides a much-needed measure of what individuals with schizophrenia are actually doing in real-world contexts. These results also suggest that there may be important disjunctions between indices of abilities and actual real-world functioning.

Neurocognitive and theory of mind deficits, dysfunctional attitudes, and negative symptoms have all been linked to poor functioning in schizophrenia, but interactions among these factors have not been extensively examined. We investigated whether dysfunctional attitudes (e.g., defeatist performance beliefs and social disinterest attitudes) moderated associations between neurocognition and theory of mind and poor everyday functioning and social competence in 146 participants with schizophrenia. We examined whether cognitive deficits are more likely to influence functioning in participants with more severe dysfunctional attitudes. Social disinterest, but not defeatist performance, attitudes were found to moderate associations between cognitive deficits and social competence but not everyday functioning, such that neurocognition and theory of mind deficits were only associated with poorer social competence in participants with more severe social disinterest attitudes. In contrast, no significant moderation effects were found for defeatist performance beliefs. Findings indicate that deficits in abilities were less likely to impact social competence in participants with greater interest in socializing. It may be that greater motivation for socializing engenders increased practice and engagement in social interactions, which then leads to greater social competence despite poor cognitive abilities. Treatments that target social disinterest attitudes may lead to greater social competence and engagement.

Background: Assertive community treatment (ACT) is one of the few evidence-based practices (EBPs) for schizophrenia that is widely implemented in community mental health programs throughout the US. As such, ACT teams provide a unique opportunity for implementation of other recovery-oriented EBPs like Cognitive Behavior Therapy (CBT) and Social Skills Training (SST). Cognitive–behavioral social skills training (CBSST) is an EBP that combines CBT and SST. Identifying variables that are associated with CBSST delivery and fidelity on ACT teams may inform effective EBP implementation strategies. The current study examined the provider, team, and leadership characteristics associated with delivery and fidelity of CBSST following implementation on ACT teams. Methods: Providers (N = 97) on 9 ACT teams were trained to deliver CBSST to consumers with schizophrenia (N = 176). Results: Providers delivered 1127 sessions over 5 years. Percentage of provider time spent on administrative/non-clinical duties was inversely associated with both number of sessions delivered (r = −.23, P = .029) and fidelity (r = −.26, P = .025). Providers who delivered more sessions achieved significantly greater fidelity (general skills: r = .32, P = .005) and a trend was found suggesting providers with more confidence and positive attitudes toward CBSST achieved greater fidelity (r = .22, P = .06). More sessions were delivered by younger providers (r = −.21, P = .040) and women (r = .23, P = .023), but provider demographics were not significantly associated with fidelity. Providers with a Master’s degree or higher (48%) did not differ significantly in delivery (t(95) =1.07, P = .287, d = .21) or fidelity (t(74) = 0.72, P = .476, d = .16) from providers with less education, and years of formal mental health education was not significantly correlated with fidelity (r = .09, P = .452) or delivery (r = −.11, P = .288). Greater ACT team responsiveness to consumers’ needs (e.g., “Members of my ACT team are expected to place the well-being of clients first”) was associated with higher fidelity (r = .24, P = .035) and greater ACT team expectations for resistance and apathy in providers (e.g., “Members of my ACT team are expected to stay uninvolved”) were associated with lower delivery (r = −.24, P = .021 and r = −.24, P = .021, respectively). Conclusion: These findings suggest future EBP implementation strategies that focus on bolstering provider confidence and positive EBP attitudes (e.g., through rapid positive fidelity feedback) and coaching leadership to facilitate an organizational climate on teams that is more responsive and less resistant may facilitate greater EBP delivery and fidelity in the context of the ACT service delivery system.

Background: Recent research has explored relationships among stigma, self-esteem, defeatist performance attitudes, and outcomes in schizophrenia. Internalized stigma has been associated with diminished self-esteem, hopelessness, and defeatist performance attitudes that have been associated with symptoms and poor functioning in schizophrenia. Internalized stigma can be viewed as self-defeating beliefs linked to illness, whereas defeatist attitudes as measured with the Defeatist Performance Attitude Scale (DPAS) are more generalized defeatist beliefs that may come from self-stigma related to illness as well as other factors such as failure experiences that are not attributed to illness. Methods: This study examined the relationships between these constructs as measured by the DPAS (Cane, Olinger, Gotlib, & Kuiper, 2006), the short form of the Self-Stigma of Mental Illness Scale (SSMIS-SF) and the Self-Esteem Rating Scale (SERS), and the Beck Hopelessness Scale (BHS). Participants (N = 60) enrolled in a randomized clinical trial for older adults with schizophrenia (mean age = 56) completed these assessments along with a battery of symptom, functioning, and neuropsychological measures. Results: Defeatist attitudes were moderately correlated with the Apply to Self (r = .453, P = .000), and Harm to Self-Esteem (r = .349, P = .006) subscales of the SSMIS-SF as well as both SERS subscales (positive: r = −.332, P = .002, negative: r = .461, P = .000), hopelessness (r = .391, P = .000), positive symptoms (Positive and Negative Syndrome (PANSS) positive subscale: r = .421, P < .001), and performance-based functioning (Maryland Assessment of Social Competence: r = −.274, P = .013). Both subscales of the SSMIS were correlated with SERS positive (r = −.454, P = .000, = −.419, P = .001) and negative (r = .553, P = .000, r = .552, P = .000) self-esteem, hopelessness (r = .335, P = .000, r = .372, P = .000), and positive symptoms (r = .256, P = .048, r = .308, P = .017). Simultaneous regressions with both SSMIS subscales and DPAS as predictors were significant only for SERS positive (R2 = .226, F(3, 55) = 5.342, P < .003) and SERS negative (R2 = .385, F(3, 55) = 11.467, P < .000) self-esteem, hopelessness (R2=.216, F(3, 55) = 5.036, P < .004), and PANSS positive symptoms(R2 = .159, F(3, 56) = 3.540, P < .020). In these models, defeatist attitudes, but not the stigma subscales, were a significant independent predictor of SERS negative (but not positive) self-esteem (βstd = .271, P = .027), hopelessness (βstd = .284, P = .039), and positive symptoms (βstd = .283, P = .044). Conclusion: Thus, despite some overlap between these constructs, generalized defeatist beliefs were a stronger predictor of important outcomes in schizophrenia than self-stigma. These findings suggest, while both types of defeatist attitudes can be productive targets for interventions such as cognitive behavior therapy, reducing severity of more generalized defeatist attitudes may produce better outcomes.

BACKGROUND: The hypothesis that defeatist performance attitudes are associated with decreased goal-directed task effort and negative symptoms in consumers with schizophrenia was investigated by using pupillary responses as a biomarker of task effort. Pupillary dilation during cognitive tasks provides a biomarker of effort devoted to the task, with greater dilation indicating greater effort.METHODS: Defeatist attitudes were assessed in 149 consumers with schizophrenia or schizoaffective disorder and 50 healthy control subjects, and consumers were divided into three groups (tertile split) with respect to severity of defeatist attitudes. Pupillary dilation responses were recorded during a digit-span task with three-, six-, and nine-digit spans.RESULTS: Effort allocation (pupillary responses) to the task increased as the processing load increased from low (three-digit) to moderate (six-digit) demands in healthy control subjects and consumers with schizophrenia with mild and moderate severity of defeatist attitudes. In contrast, consumers with severe defeatist attitudes did not increase their effort when processing demands increased from low to moderate loads. These consumers showed significantly less effort in the six-digit condition relative to consumers with mild defeatist attitudes. Moreover, consumers with severe defeatist attitudes showed significantly greater severity of negative symptoms relative to consumers with mild defeatist attitudes and negative symptoms were significantly correlated with defeatist attitudes.CONCLUSIONS: These results suggest a relationship between defeatist performance attitudes, goal-directed task effort indexed by pupillary responses, and negative symptoms in schizophrenia. The findings have implications for using cognitive therapy to reduce defeatist attitudes that may contribute to diminished effort and negative symptoms in schizophrenia.

Goal attainment scaling (GAS) is described as a method for standardizing achievement of personalized recovery goals. Collaborative goal setting enhances hope and motivation and promotes recovery for consumers with serious mental illness (SMI). Many available outcome measures survey broad functioning domains (e.g., work, school) and not personalized recovery goals that match consumers' self-determined needs and preferences. GAS was utilized to measure goal progress in consumers with schizophrenia and schizoaffective disorder (N = 55) in a clinical trial of group psychosocial interventions. Goals included 10 steps with objective anchors, which were measured at three time points (baseline, midtreatment, and end of treatment). Hierarchical linear modeling evaluated change over time. The most common goal chosen by consumers was establishing or reestablishing relationships, followed by self-care, employment, leisure activities, housing, school, independent transportation, recovery from addictions, and money management. Results indicated a significant increase in mean goal attainment with scores increasing from 2.38 (SD = 1.69)—corresponding to “talks to support person about goal”—at baseline to 5.64 (SD = 2.31)—corresponding to “actively engages in goal activity/behavior at least once”—at end of treatment. This preliminary evidence suggests the GAS measure is sensitive to change in a clinical trial. GAS is a promising recovery-oriented therapeutic tool and functional outcome measure for consumers with SMI.

OBJECTIVEIdentifying treatments to improve functioning and reduce negative symptoms in consumers with schizophrenia is of high public health significance.METHODIn this randomized clinical trial, participants with schizophrenia or schizoaffective disorder (N = 149) were randomly assigned to cognitive behavioral social skills training (CBSST) or an active goal-focused supportive contact (GFSC) control condition. CBSST combined cognitive behavior therapy with social skills training and problem-solving training to improve functioning and negative symptoms. GFSC was weekly supportive group therapy focused on setting and achieving functioning goals. Blind raters assessed functioning (primary outcome: Independent Living Skills Survey [ILSS]), CBSST skill knowledge, positive and negative symptoms, depression, and defeatist performance attitudes.RESULTSIn mixed-effects regression models in intent-to-treat analyses, CBSST skill knowledge, functioning, amotivation/asociality negative symptoms, and defeatist performance attitudes improved significantly more in CBSST relative to GFSC. In both treatment groups, comparable improvements were also found for positive symptoms and a performance-based measure of social competence.CONCLUSIONSThe results suggest CBSST is an effective treatment to improve functioning and experiential negative symptoms in consumers with schizophrenia, and both CBSST and supportive group therapy actively focused on setting and achieving functioning goals can improve social competence and reduce positive symptoms.

OBJECTIVES:To determine whether Cognitive Behavioral Social Skills Training (CBSST) is an effective psychosocial intervention to improve functioning in older consumers with schizophrenia, and whether defeatist performance attitudes are associated with change in functioning in CBSST. DESIGN:An 18-month, single-blind, randomized controlled trial. SETTING:Outpatient clinic at a university-affiliated Veterans Affairs hospital. PARTICIPANTS:Veteran and non-veteran consumers with schizophrenia or schizoaffective disorder (N = 79) age 45-78. INTERVENTIONS:CBSST was a 36-session, weekly group therapy that combined cognitive behavior therapy with social skills training and problem-solving training to improve functioning. The comparison intervention, goal-focused supportive contact (GFSC), was supportive group therapy focused on achieving functioning goals. MEASUREMENTS:Blind raters assessed functioning (primary outcome: Independent Living Skills Survey), CBSST skill mastery, positive and negative symptoms, depression, anxiety, defeatist attitudes, self-esteem, and life satisfaction. RESULTS:Functioning trajectories over time were significantly more positive in CBSST than in GFSC, especially for participants with more severe defeatist performance attitudes. Greater improvement in defeatist attitudes was also associated with better functioning in CBSST, but not GFSC. Both treatments showed comparable significant improvements in amotivation, depression, anxiety, positive self-esteem, and life satisfaction. CONCLUSIONS:CBSST is an effective treatment to improve functioning in older consumers with schizophrenia, and both CBSST and other supportive goal-focused interventions can reduce symptom distress, increase motivation and self-esteem, and improve life satisfaction. Participants with more severe defeatist performance attitudes may benefit most from cognitive behavioral interventions that target functioning. TRIAL REGISTRY:ClinicalTrials.Gov #NCT00237796 (http://clinicaltrials. gov/show/NCT00237796).