Homelessness, Mental Health Conditions
Conditions
Keywords
Homeless persons, Veterans, Mental disorders, Cognition, Rehabilitation
Brief summary
Cognitive impairments are present in up to 80% of homeless individuals, and may contribute to homelessness in Operation Enduring Freedom / Operation Iraqi Freedom / Operation New Dawn (OEF/OIF/OND) Veterans. The investigators propose to investigate these issues in homeless, treatment-seeking returning Veterans, who arguably face multiple potential barriers to recovery and reintegration, and with whom there is the greatest opportunity to prevent long-term homelessness. The investigators plan to conduct a 15-week randomized controlled trial of an evidence-based, 10-week Compensatory Cognitive Training (CCT) intervention vs. an education control condition to examine the effects of cognitive rehabilitation in this Veteran population. The investigators expect CCT-associated improvements in cognition and functional skills and generalization to reduced levels of disability, along with improved community reintegration outcomes. By attending to and treating cognitive impairments, the investigators can potentially prevent future homelessness and its negative health consequences, resulting in both healthcare cost savings and improved quality of life for Veterans.
Detailed description
This study integrates cognitive rehabilitation in residential care for homeless Veterans. In a 15-week randomized controlled trial, the investigators will compare an evidence-based, 10-week Compensatory Cognitive Training (CCT) intervention to an education control condition for homeless Veterans with cognitive impairment. CCT aims to improve real-world cognitive performance by teaching strategies to improve prospective memory (remembering to do things), attention, learning/memory, and executive functioning. Strategies to reduce stress and improve sleep are also included. CCT has been shown to improve cognition, functional capacity, neurobehavioral symptom severity, and quality of life in individuals with cognitive impairment associated with psychiatric illness and in Veterans with traumatic brain injury (TBI). During the trial, assessments will be administered at baseline, 5 weeks, 10 weeks, and 15 weeks, and monthly follow-up phone calls will assess housing and employment/education status for one year following program discharge. The investigators expect CCT-associated improvements in cognition and functional skills (co-primary outcomes) and generalization to reduced levels of disability, along with improved community reintegration outcomes (better housing stability, participation in work or school, and healthcare appointment attendance). If effective, the CCT intervention could be exported to the 80+ residential VA programs serving homeless Veterans. The investigators thus propose the following aims: Aim 1. Investigate the efficacy of cognitive rehabilitation in homeless returning Veterans with mental health conditions and cognitive impairment by conducting a randomized controlled trial of Compensatory Cognitive Training (CCT) vs. education control for 10 weeks, with a 5-week follow-up, followed by 1 year of monthly post-discharge follow-up phone calls to assess community reintegration outcomes. H1a: Positive CCT-associated effects on cognition, functional capacity (co-primary outcomes), and disability will emerge over the 15-week study. H1b: Positive CCT-associated effects on community reintegration outcomes (housing stability, participation in employment/education, healthcare appointment attendance) will be detected at the end of the 1-year follow-up. Aim 2. Investigate mechanisms of CCT effects. H2: Improved cognition and cognitive strategy use will mediate improvements in functional capacity, disability, and community reintegration. Exploratory Aim 3. Investigate moderators of CCT effects. Presence and severity of Posttraumatic Stress Disorder (PTSD), depression, history of substance abuse, and TBI, as well as duration of homelessness and baseline cognitive functioning, will be explored as potential moderators of CCT effects.
Interventions
BEHAVIORALCCT
10-week Compensatory Cognitive Training
BEHAVIORALHCE
10-week Holistic Cognitive Education
Sponsors
VA Office of Research and Development
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
SINGLE (Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to 55 Years
Healthy volunteers
No
Inclusion criteria
* Male or female * Any race/ethnicity * Age 18-55 * Receiving residential treatment at the VA San Diego Aspire Center * Meets criteria for Aspire Center program entry * OEF/OIF/OND Veteran * Presence of at least one DSM-V mental health condition * Does not meet criteria for substance use disorder for 28 days prior to admission * Homeless or unstably housed * Not a sex offender or violent offender * Capable of performing activities of daily living and transfers * Not judged by a clinician to be at current risk to self or others * Has cognitive impairment in at least one cognitive domain (i.e., T-score \<40) * Able to speak and read English * Capable of and willing to provide signed informed consent
Exclusion criteria
None.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change in Global Deficit Score From Expanded MATRICS Consensus Cognitive Battery (MCCB) | baseline to 15 weeks | Global Deficit Score (composite score) from MATRICS Consensus Cognitive Battery plus Delis-Kaplan Executive Function System (D-KEFS) subtests (Verbal Fluency, Color-Word Interference), Trail Making Test, Part B Global deficit score range = 0-5, lower scores are better, higher scores are worse. For change in global deficit score, higher is better. |
| Change in UCSD Performance-Based Skills Assessment-Brief (UPSA-B) | baseline to 15 weeks | Performance-based functional capacity in finance and communication UPSA scores range from 0-100, higher scores are better. For change in UPSA scores, higher is also better. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Change in World Health Organization Disability Assessment Schedule (WHODAS) 2.0 | baseline to 15 weeks | Measure of level of disability WHODAS scores range from 0-100, higher scores are worse. For change in WHODAS scores, higher scores are also worse. |
Countries
United States
Participant flow
Recruitment details
79 participants were enrolled and randomized to a condition and were included in intent to treat analyses, but 10 dropped out before starting their assigned intervention (5 in each arm).
Participants by arm
| Arm | Count |
|---|---|
| Compensatory Cognitive Training (CCT) Compensatory Cognitive Training
CCT: 10-week Compensatory Cognitive Training | 39 |
| Holistic Cognitive Education (HCE) Holistic Cognitive Education
HCE: 10-week Holistic Cognitive Education | 40 |
| Total | 79 |
Baseline characteristics
| Characteristic | Compensatory Cognitive Training (CCT) | Holistic Cognitive Education (HCE) | Total |
|---|---|---|---|
| Age, Continuous | 37.6 years STANDARD_DEVIATION 7.7 | 37.0 years STANDARD_DEVIATION 6.9 | 37.3 years STANDARD_DEVIATION 7.3 |
| Ethnicity (NIH/OMB) Hispanic or Latino | 9 Participants | 12 Participants | 21 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 30 Participants | 28 Participants | 58 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 2 Participants | 3 Participants | 5 Participants |
| Race (NIH/OMB) Asian | 0 Participants | 2 Participants | 2 Participants |
| Race (NIH/OMB) Black or African American | 4 Participants | 5 Participants | 9 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 1 Participants | 0 Participants | 1 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 3 Participants | 5 Participants | 8 Participants |
| Race (NIH/OMB) White | 29 Participants | 25 Participants | 54 Participants |
| Sex: Female, Male Female | 0 Participants | 1 Participants | 1 Participants |
| Sex: Female, Male Male | 39 Participants | 39 Participants | 78 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 0 / 39 | 0 / 40 |
| other Total, other adverse events | 0 / 39 | 0 / 40 |
| serious Total, serious adverse events | 0 / 39 | 0 / 40 |
Outcome results
Primary
Change in Global Deficit Score From Expanded MATRICS Consensus Cognitive Battery (MCCB)
Global Deficit Score (composite score) from MATRICS Consensus Cognitive Battery plus Delis-Kaplan Executive Function System (D-KEFS) subtests (Verbal Fluency, Color-Word Interference), Trail Making Test, Part B Global deficit score range = 0-5, lower scores are better, higher scores are worse. For change in global deficit score, higher is better.
Time frame: baseline to 15 weeks
Population: All participants who completed a baseline assessment (i.e., intent to treat sample)
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Compensatory Cognitive Training (CCT) | Change in Global Deficit Score From Expanded MATRICS Consensus Cognitive Battery (MCCB) | 0.26 score on a scale | Standard Deviation 0.47 |
| Holistic Cognitive Education (HCE) | Change in Global Deficit Score From Expanded MATRICS Consensus Cognitive Battery (MCCB) | .14 score on a scale | Standard Deviation 0.12 |
Primary
Change in UCSD Performance-Based Skills Assessment-Brief (UPSA-B)
Performance-based functional capacity in finance and communication UPSA scores range from 0-100, higher scores are better. For change in UPSA scores, higher is also better.
Time frame: baseline to 15 weeks
Population: All participants with baseline data included (i.e., intent to treat sample)
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Compensatory Cognitive Training (CCT) | Change in UCSD Performance-Based Skills Assessment-Brief (UPSA-B) | 8.3 score on a scale | Standard Deviation 8.9 |
| Holistic Cognitive Education (HCE) | Change in UCSD Performance-Based Skills Assessment-Brief (UPSA-B) | 8.3 score on a scale | Standard Deviation 8.6 |
Secondary
Change in World Health Organization Disability Assessment Schedule (WHODAS) 2.0
Measure of level of disability WHODAS scores range from 0-100, higher scores are worse. For change in WHODAS scores, higher scores are also worse.
Time frame: baseline to 15 weeks
Population: All participants with baseline data (i.e., intent to treat sample)
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Compensatory Cognitive Training (CCT) | Change in World Health Organization Disability Assessment Schedule (WHODAS) 2.0 | -5.6 score on a scale | Standard Deviation 13.2 |
| Holistic Cognitive Education (HCE) | Change in World Health Organization Disability Assessment Schedule (WHODAS) 2.0 | -4.5 score on a scale | Standard Deviation 8.4 |