There is growing evidence that the majority of the psychosocial deterioration that accompanies psychotic disorders occurs during the first few years of illness [1–3] and that the prevention or delay of early deterioration may be associated with a better course of illness [4–7]. One intervention which has been shown to be particularly effective in the treatment of psychotic disorders is family psychoeducation--an umbrella term for a group of interventions that provide families with education about psychotic disorders and strategies to improve problem-solving skills and communication within the family . To date, multiple studies have demonstrated that the receipt of family psychoeducation is associated with lower rates of relapse among individuals with psychotic disorders [9, 10] with individuals with first-episode psychosis experiencing greater clinical benefits than individuals later in the course of a psychotic disorder [11, 12].
One particular form of family psychoeducation which has shown promise among individuals with first-episode psychosis is multifamily group psychoeducation (MFG) . This intervention provides participants with information about the course and treatment of psychotic disorders and trains participants in the use of a structured problem-solving exercise designed to help them navigate the many challenges associated with living with a psychotic disorder or caring for a relative with a psychotic disorder. Among individuals with psychotic disorders, participation in MFG is associated with reduced rates of relapse [13, 14], and the clinical benefit of this intervention appears to be greater among individuals with first-episode psychosis as opposed to individuals with a chronic psychotic disorder . The success of this intervention among individuals with first-episode psychosis has led to the incorporation of MFG within several major international studies of first-episode psychosis (e.g., OPUS  and TIPS ).
However, like all psychosocial interventions, some individuals who participate in MFG will still experience negative health outcomes. With regard to individuals with first-episode psychosis, approximately 20% may experience a symptomatic relapse and 50% may be hospitalized over a two-year period despite participating in family psychoeducation [11, 13]. Thus, despite the clear clinical benefits associated with participation in MFG, there is still room for improvement with regard to the clinical outcomes of individuals who participate in this intervention.
One factor that may limit the benefit of psychosocial treatments (e.g., MFG) for psychosis is the cognitive deficits that tend to accompany psychotic disorders [17, 18]. Cognitive deficits in areas such as problem-solving ability, verbal memory, and attention are common in individuals with psychotic disorders [19, 20] (including those early in the course of a psychotic disorder [21, 22]) and have been recognized as a "rate-limiting" factor which may hinder individuals' ability to learn and execute new skills [18, 23]. In the context of MFG, these cognitive deficits may hinder an individual's ability to learn and participate in the problem-solving activity which is the hallmark of MFG. Addressing these cognitive deficits, in particular those related to problem-solving, could potentially facilitate greater participation and understanding of the MFG problem-solving activity among individuals with first-episode psychosis--thereby facilitating greater clinical benefits associated with participation in this intervention.
Recently, greater attention has been directed toward the development of strategies to ameliorate the cognitive deficits that accompany psychotic disorders. One strategy which has been shown to be successful in this endeavor is cognitive remediation (CR). This intervention, which is recognized as a "best practice" in the treatment of psychotic disorders [24, 25], is typically comprised of a series of repeated exercises delivered by a clinician or via a computer that are designed to improve performance in cognitive functioning. A recent-meta-analysis has shown that participation in cognitive remediation programs is associated with improvements in multiple domains of cognitive functioning, including problem-solving ability . The success of CR in improving problem-solving skills (and other areas of cognitive functioning) raises the possibility that individuals with first-episode psychosis who participate concurrently in MFG and CR may be better able to learn and apply the problem-solving activity completed during MFG sessions. This, in turn, could lead to improvements in outcomes experienced by these individuals.
Thus, the goal of this study is to examine whether concurrent participation in MFG and CR is associated with better outcomes among individuals with first-episode psychosis than participation in MFG alone. We hypothesize that relapse rates will be lower among individuals who participate in the MFG and CR condition as opposed to MFG alone. However, recognizing that the benefits of MFG and CR may not be limited to relapse alone, we will also examine the benefits of these interventions with regard to secondary outcome measures for both individuals with first-episode psychosis and their caregiving relatives.