Uncontrolled trial of specialized, multi‐component care for individuals with first‐episode psychosis: Effects on motivation orientations

Abstract Aim Deficits in motivation are present early in the course of psychotic disorders. However, growing data have highlighted important heterogeneity in motivation among individuals with psychosis, suggesting that this variable may not be a unitary concept. Outside of the psychosis literature, research on self‐determination theory has identified three motivational orientations that guide the initiation and regulation of behaviour: autonomous, controlled and impersonal. Thus, our study goal is to investigate the longitudinal course of motivational orientations among individuals participating in a specialized clinical service for individuals with first‐episode psychosis (ie, coordinated specialty care: CSC). Methods Forty‐one individuals with first‐episode psychosis participating in CSC completed assessments of motivation orientations at enrolment and after 6 months of care. Results Whereas there were no changes in controlled or impersonal orientations over the first 6‐months of care, individuals with first‐episode psychosis reported an increase in autonomous orientations. Moreover, while individuals with first‐episode psychosis reported lower autonomous orientations at enrolment as compared to individuals without psychosis, after 6 months of care, ratings of autonomous orientations among individuals with first‐episode psychosis were equivalent to those of individuals without psychosis. Conclusions Although the results should be interpreted cautiously given the uncontrolled study design, the results suggest that the benefits of participation in early intervention services for psychosis may extend to improvements in motivation.


| INTRODUCTION
Deficits in motivation are present early in the course of psychotic disorders and are associated with poor concurrent and future functional status among individuals with first-episode psychosis (FEP: Faerden et al., 2009;Fervaha, Foussias, Agid, & Remington, 2013;Fulford et al., 2017;Schlosser et al., 2014). However, growing data have highlighted important heterogeneity in motivation among individuals with psychosis, suggesting that this variable may not be a unitary concept (Luther, Firmin, Lysaker, Minor, & Salyers, 2018;Luther, Fischer, Firmin, & Salyers, 2019). For example, a recent meta-analysis demonstrated that the association between negative symptoms and selfreported motivation among individuals with schizophrenia was moderated by the domain of motivation assessed. More specifically, whereas both self-reported ratings of intrinsic motivation and amotivation were associated with negative symptoms, self-reported extrinsic motivation was not (Luther et al., 2019).
Outside of the psychosis literature, research on self-determination theory (Ryan & Deci, 2000) has identified three, non-independent motivational orientations-sometimes referred to as "causality orientations"-that guide the initiation and regulation of human behaviour: autonomous, controlled and impersonal. For example, whereas individuals with a predominantly autonomous orientation are primarily motivated by intrinsic factors and are drawn to environments that allow for greater choice and self-regulation of behaviour, individuals with a predominantly controlled orientation are largely motivated by extrinsic factors such as rewards or punishments (Deci & Ryan, 1985). Conversely, individuals with a predominantly impersonal orientation view themselves as unable to control their own personal behaviour or events in their environment (Deci & Ryan, 1985), resulting in greater amotivation (Cooper, Lavaysse, & Gard, 2015).
In the sole investigation of motivation orientations among individuals with FEP completed to date, Breitborde, Kleinlein, and Srihari (2014) found that individuals with FEP endorsed greater autonomous orientations than controlled and greater controlled orientations than impersonal-a pattern identical to that found in quasi-normative data for individuals with no known psychotic disorder. However, betweengroup comparisons revealed that individuals with FEP reported lower autonomous orientations and greater impersonal and controlled orientations as compared to the quasi-normative data for individuals with no known psychotic disorder. In total, these results suggest that although individuals with FEP are primarily motivated by intrinsic factors (ie, autonomous orientation), they are more likely than individuals without psychosis to be motivated by extrinsic factors (ie, controlled orientation) or feel incapable of controlling their own behaviour or events in their environment (ie, impersonal orientation).
Internationally, there is a widespread adoption and dissemination of specialized treatment programs for individuals with FEP Breitborde, Moe, Ered, Ellman, & Bell, 2017). These programs provide access to evidence-based psychosocial and pharmacological interventions and have shown great promise in facilitating improved symptomatology and functioning among individuals early in the course of a psychotic disorder (Correll et al., 2018). More recently, greater attention has been directed toward the importance of facilitating increased motivation among individuals with FEP participating in such services both as a primary outcome as well as a strategy to optimize treatment engagement and outcomes Mueser, Glynn, & Meyer-Kalos, 2017) and many programs include motivational enhancement activities within their clinical services. Examples of such activities include utilization a shared decision-making model in treatment planning, incorporating youth and young adults in the design of specialized clinical services for first-episode psychosis and delivering care in youth-friendly environments (Breitborde, Labrecque, Moe, Gary, & Meyer, 2018;Breitborde & Moe, 2019;Pollard, Cahill, & Srihari, 2016). Yet, limited research has examined the effect of participation in such specialized clinical programs on motivation among individuals with FEP. In one notable exception, Kane et al. (2016) found that individuals with FEP participating in the NAVIGATE intervention package experienced greater gains in the intrapsychic foundations subscale of the Quality of Life Scale (QLS: Heinrichs, Hanlon, & Carpenter, 1984) than individuals with FEP participating in usual care. A recent psychometric evaluation of the QLS suggests that the intrapsychic foundations subscale may be best conceptualized as assessing motivation (Mueser, Kim, et al., 2017); thus, the Kane et al. (2016) (Wilkinson & Robertson, 2006). Demographic data with regard to study participants are shown in Table 1.

| Motivation orientations
Participants completed the General Causality Orientation Scale (GCOS: Deci & Ryan, 1985;Hodgins, Koestner, & Duncan, 1996) upon enrolment to EPICENTER and after approximately 6 months of treatment (M = 6.28). This scale is comprised of 17 vignettes describing social or achievement situations that are followed by three different interpretations of the situation that map onto autonomous, controlled and impersonal motivational orientations, respectively. Participants rate the likelihood that they would make each of the three interpretations in these situations on a 1 to 7 scale with higher scores indicating a greater likelihood to make the interpretation. Score on the GCOS have been found to be associated with other measures of motivational processes both within and outside of the psychosis literature (eg, Cooper et al., 2015;Neighbors, Vietor, & Knee, 2002).

| Interventions
Individuals participating in care at EPICENTER are provided with access to a menu of interventions including medication management, cognitive behavioural therapy (Breitborde & Moe, 2016a) and a step-based family psychoeducation program (Breitborde, 2015). While EPICENTER participants were initially provided with access to computerized cognitive remediation, this was later replaced with metacognitive remediation therapy (Breitborde & Moe, 2016b) given the superiority of the latter to the former with regard to improvements in cognitive, social and educational/occupational functioning (Breitborde, Woolverton, et al., 2017). Selection of specific interventions is determined using a shared decision-making process and is informed by clinical assessments of functioning and symptomatology completed at enrolment.

| Statistical analyses
Missing data were addressed using multiple imputation (Enders, 2017). The fraction of missing information (λ) for all analyses ranged from 0.11 to 0.48 and never reached levels that would be considered problematic with regard to the accuracy of parameter estimates (Savalei & Rhemtulla, 2012).
Cross-sectional comparisons of GCOS data were completed using paired and unpaired t tests, respectively. Longitudinal changes in GCOS scores were evaluated using Hedberg and Ayers' (2015) regressionbased test for paired-data using robust regression procedures (Wilcox & Keselman, 2004). To aid in interpretation of the results, effect sizes effect sizes are for within-subjects for within-subjects (d av : Cumming, 2012) and between-subjects analyses (Cohen's d s : Cohen, 1988) are provided. In situations in which there was not a statistically significant difference between GCOS scores for individuals with FEP vs quasinormative GCOS scores, equivalence testing was completed using Meyners' least equivalent allowable distance (LEAD). Within the context of the current study, equivalence testing evaluates the null hypothesis that GCOS scores for individuals with FEP differ from quasi-normative GCOS scores by a value (δ) that represents a clinically-meaningful difference in GCOS scores (Lakens, Scheel, & Isager, 2018). Rejection of this null hypothesis is consistent with the conclusion that GCOS scores for individuals with FEP are equivalent to quasi-normative values. LEAD equivalence testing accomplishes goal by identifying the largest value of δ at which the symmetrical null hypothesis of an equivalence test would be rejected at α = .05 (Meyners, 2007).  Table 2. GCOS scores at baseline were not associated  Although there were no longitudinal changes in controlled or impersonal orientations, individuals with FEP reported an increase in autonomous orientations over their first 6 months of care at EPICENTER such that their 6-month scores were statistically equivalent to quasinormative GCOS data for individuals with no known psychotic disorder.

| Six-month motivation orientations
In total, these data have several important implications with regard to our understanding of motivation among individuals with FEP. First, data with regard to controlled orientations suggests that the appeal of extrinsic reinforcers may remain intact among individuals with FEPsuggesting that external reinforcers may remain key drivers of motivation for these individuals. Specialized treatment programs for individuals with FEP may benefit from incorporation of opportunities for extrinsic reinforcers within their clinical setting to facilitate increased engagement in care and to promote improved clinical outcomes (Breitborde et al., 2014). Outside of the FEP literature, extrinsic reinforcers have been shown to be a powerful motivational aid within cognitive remediation programs for individuals with schizophrenia to facilitate improvements in cognition and functioning (Silverstein, 2010). Second, our data comport with evidence outside of the schizophrenia literature highlighting the multidimensional nature of motivation (Vallerand, 1997 Negative symptoms, such as amotivation, are important targets for treatment given their clear association with poor concurrent and future functional status among individuals with first-episode psychosis (Faerden et al., 2009;Fervaha et al., 2013;Fulford et al., 2017;Schlosser et al., 2014). Yet, while recent meta-analyses suggest that pharmacological and psychosocial treatments produce statistical reductions in negative symptom severity (Leucht, Arbter, Engel, Consequently, effective treatments for negative symptoms remain a largely unmet need within mental health care (Kirkpatrick, Fenton, Carpenter, & Marder, 2006). The results of the current study add to a growing corpus of research highlighting the benefits of participation in specialized early intervention services on the course of negative symptoms among individuals with psychosis (eg, Grawe, Falloon, Widen, & Skogvoll, 2006;Thorup et al., 2005). With regard to motivational dysfunction specifically, the benefits of such specialized clinical services may suggest that the early period of the illness may represent a critical period in which to minimize and/or prevent further decreases in motivation (Luther, Lysaker, Firmin, Breier, & Vohs, 2015). Consistent with this hypothesis, Lutgens et al. (2019) found that whereas individuals with first-episode psychosis experienced reductions in amotivation over the first two years of participation in a specialized early intervention service, levels of amotivation remained relatively stable over the subsequent three years of participation in this clinical service.
It is important to note that the current study does suffer from

CONFLICT OF INTEREST
Dr Breitborde and Dr Moe have received salary support from IMHR to support the launch of a specialized clinic for individuals with firstepisode psychosis.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.