The International Journal of Psychosocial Rehabilitation

The Influence Of Psychosocial Rehabilitation
On Patients With A First Episode Of Psychosis

 

Peter Whitty MD, MRCPsych.

Coolock Mental Health Centre,

Coolock
Dublin 17
Ireland

 

Caroline Lydon

Burton Hall

Sandyford Industrial Estate

 

Nial Turner

Burton Hall
Sandyford Industrial Estate

 

Professor Eadbhard O’Callaghan MD, FRCPsych

Professor of Psychiatry and Consultant Psychiatrist

Cluain Mhuire Family Centre
Newtownpark Avenue
Blackrodk
Co. Dublin
Ireland

 

From the Stanley Research Unit, Cluain Mhuire Family Centre, Blackrock and St John of God Hospital, Stillorgan,
 Co. Dublin and St Vincent’s University Hospital, Elm Park, Dublin 4 and University College Dublin.

 

  Citation:
Whitty P., Lydon C., Turner N., & O'Callaghan E. (2006). The Influence Of Psychosocial Rehabilitation On Patients
 With A First Episode Of Psychosis.
  International Journal of Psychosocial Rehabilitation.
10 (2) 17-27.


 

Address for correspondence:

Professor Eadbhard O' Callaghan, Stanley Research Unit, Department of Adult Psychiatry, St John of God Hospital and Cluain Mhuire Family Centre, Newtownpark Avenue, Blackrock, Co. Dublin, Ireland.

Telephone        +353 1 2833766

Fax                  +353 1 2833886

Email                eadbhard@gmail.com  

 

Funding: This work was supported by the Stanley Medical Research Institute



 

Abstract

Psychosocial interventions offer an important adjunct to pharmacotherapy in the treatment of psychosis. We examined the effects of a psychosocial rehabilitation programme by comparing first presentation and 4-year follow-up assessments among 96 first-episode psychosis patients. At first-presentation, those who completed the programme (N = 19) had a significantly poorer quality of life than those who received standard care (N = 77). At follow-up there were no statistically significant differences in quality of life between the two groups. We conclude that psychosocial rehabilitation should form an integral part of the treatment of psychosis and may offer distinctive benefits in improving the quality of life of such patients.

 

Key Words: Psychosis, rehabilitation, outcome



Introduction

Despite recent advances in the pharmacological management of the psychoses up to 80% of patients with schizophrenia experience more than one episode of psychosis. Additionally, the prognosis of affective disorder, traditionally thought to be more favourable, can be poor especially for those with psychotic symptoms (Wiersma, 1998; Robinson, 1999; Ohmori, 1999; Shepherd, 1989; Lee & Murray, 1989).  Approximately 30% of patients with psychosis respond poorly to medication and continue to evidence persistent symptoms and functional impairment (Kane, 1988). Furthermore, pharmacological treatment on its own has only a moderate impact on the social function of patients with schizophrenia (Frangou & Murray, 2000).

 

Psychosocial rehabilitation offers an important adjunct to pharmacotherapy (Bachrach, 2000) and may offer unique benefits to patients with psychosis (Bacharach, 1992; Bachrach 1996). The goal of these interventions is to enable individuals to achieve the highest feasible quality of life by ensuring that they can perform the physical, emotional, social and intellectual skills required to live in the community (Anthony, 1988). Yet the potential benefits of psychosocial rehabilitation may not be fully understood as there is a relative shortage of published research in the area particularly among persons with a first-episode of psychosis (Huxley, 2000).

 

We sought to investigate the effectiveness of a psychosocial rehabilitation programme on the outcome of a group of patients recovering from a first-episode of psychosis. We compared the outcomes of those who attended the programme with those who received standard care to determine the effectiveness of the intervention.

 

Method

Subjects

Between 1995 and 1999 we conducted a first episode psychosis study at Cluain Mhuire Family Centre (a catchment area service which provides community based psychiatric care for an urban population in County Dublin of approximately 165 000) and St. John of God Hospital, County Dublin (Browne, 2000). The study received Ethics (Research) Committee approval. First episode psychosis was defined as a first ever presentation to any psychiatric service with a psychotic episode. Patients who commenced antipsychotic medication prior to referral were included in the study provided they were being treated for a first psychotic episode and that their treatment had not commenced more than 30 days before assessment. A further ethical submission was accepted and patients were followed-up 4 years after initial presentation. They were reassessed across the same clinical measures by an investigator blind to original clinical measures. As part of treatment for a first-episode of psychosis a subgroup of patients were referred to a psychosocial rehabilitation programme at one of our centres. Treating teams made referrals, the programme was open to all who presented with a first-episode of psychosis during the study period and all participants gave informed consent to study participants. 

 

The REACH Programme (Recognition & Esteem through Accommodation, Catering and Horticulture) is a 32 week fulltime lifestyle management course. The aim of the programme is to enable participants to develop the necessary skills and confidence to achieve health and well-being with the goal of returning to work or progressing onto further training. Mental health education is an important aspect of the programme and aims to develop knowledge about illness, medication, relapse prevention and early warning signs. Other areas addressed in the programme include alcohol and substance misuse, communication skills, self-awareness and self-esteem, job seeking skills, generic work skills, teamwork, goal setting and use of community resources. The present study compared the outcome at 4-year follow-up of those who attended the psychosocial rehabilitation course with those who received standard care.

 

Clinical Measures

(a) Quality of life: We measured quality of life using the Quality of Life Scale (QLS; Heinrichs, 1979) and the World Health Organisation Quality of Life Scale ‘Bref’ version (WHOQoLBref’; World Health Organisation, 1996). The QLS is a semistructured interviewer-administered scale. It consists of 21 items divided into 4 subscales; Interpersonal relations, Instrumental role, Intrapsychic foundations and Common objects and activities. A total score is calculated by adding the subscale scores.

We used the World Health Organisation Quality of Life Scale - Brief version (WHOQoL-'Bref'; World Health Organisation, 1996) as a subjective measure quality of life. This 28 item self-report scale assesses quality of life across 4 domains (Physical health, Psychological health, Social relationships and Satisfaction with environment).

 

(b) Positive and Negative Syndrome Scale (PANSS): Psychopathology was assessed using the PANSS (Kay, 1987). This scale is divided into 3 subscales; 7 items assess positive symptoms, 7 items assess negative symptoms and 16 items assess general psychopathology.

 

(c)    Insight: We used the Insight Scale (Birchwood, 1994) to assess degree of insight. This self-report questionnaire is well validated and extensively used among patients with schizophrenia. It measures three dimensions of insight: 'awareness of illness', 'ability to relabel psychotic symptoms', and 'recognition of the need for treatment'.  Each dimension is scored on a scale of 0-4, giving an overall insight score of 0-12 (higher score indicating greater insight).

 

All patients were diagnosed using the Structured Clinical Interview in accordance with DSM-IV criteria (APA, 1994) and we rated an individual’s Global Assessment of Functioning (GAF) (Spitzer, 1995) and degree of substance misuse as part of this interview. We also assessed attitudes and concordance with medication using the Drug Attitude Inventory (DAI; Hogan, 1983) and the Medication Compliance Interview (Adams 1993). Number of admissions and days spent in hospital were calculated from hospital records.

 

Statistics

We divided the patients into two groups; those who completed the programme and those who received standard care. We compared assessments at first presentation between the groups using t-tests for continuous data and chi square tests for categorical data. Follow-up assessments were also analysed in this manner. We used paired t-tests to compare first presentation with follow-up assessments in each of these groups. All data was analysed using the Statistical Package for Social Sciences (SPSS, 2001).

 

 

Results

Ninety-six patients (63 male, 33 female) were assessed at first presentation and at 4-year follow-up. The demographic and clinical characteristics of these patients are outlined in Table I. Their diagnoses were as follows; Schizophrenia = 80, Bipolar affective disorder = 8, Major depression = 1, Delusional disorder = 3, Drug induced psychosis = 2, Schizoaffective disorder = 2. The mean length to follow-up for the total group was 43.5 months (s.d. 9.5 months). Thirty-one patients were referred to the lifestyle management course of whom 19 completed the course and consented to follow-up assessment (Schizophrenia = 18, Bipolar affective disorder = 4, substance induced psychosis = 1, schizoaffective disorder = 1).

 

Table I. Demographic and clinical characteristics of all 96 patients at first presentation.

 

Mean

Standard deviation

Age of onset

25.81

9.26

Age at first presentation

27.62

9.85

DUP

21.68

39.05

Years in education

13.50

2.49

QLS total

63.23

25.58

GAF

22.48

7.69

PANSS total

76.43

18.03

 

DUP = Duration of untreated psychosis, QLS = Quality of life scale, GAF = Global assessment of functioning, PANSS = Positive and negative syndrome scale.

 

 

First presentation assessments

At first presentation the 19 patients who completed the REACH programme were indistinguishable from the 77 who did not in terms of age at first presentation (t = -1.48, P = 0.15), gender (c2 = 1.86, P = 0.17), duration of untreated initial psychosis (t = -0.69, P = 0.56), total PANSS score (t = 0.09, P = 0.93), insight (t = 1.67, P = 0.11), degree of alcohol / substance abuse (c2 = 0.33, P = 0.56) or GAF score (t = -0.77, P = 0.45). However, patients who completed the REACH programme had a poorer subscale and total QLS scores at first presentation compared to those who received standard care (Table II).

 

 Table II. Comparison of quality of life scores (QLS) at first presentation between patients who completed the REACH programme and those who received standard care. 


REACH programme

(N = 19)

Standard care

(N = 77)

df

t

P

95% CI

QLS Social functioning

19.5

24.4

94

-2.0

0.057

(-9.91, 0.16)

QLS Occupational functioning

6.4

11.3

94

-2.9

0.006

(-8.36, -1.48)

QLS Intrapsychic foundations

18.3

23.6

94

-2.5

0.014

(-9.53, -1.12)

QLS Common objects and activities

5.9

7.3

94

-2.3

0.029

(-2.48, -0.15)

QLS total

50.1

66.5

94

-3.0

0.005

(-27.49, -5.38)

 

Follow-up assessments

Quality of Life

 At follow-up there were statistically significant improvements in subscale and total QLS scores in both groups of patients (Table III).  However, patients who completed the REACH programme were indistinguishable from those who did not in terms of their total QLS and subscale scores (Table IV). Furthermore, even though both groups evidenced improvement in quality of life at follow-up, this improvement was most marked among patients who attended the psychosocial rehabilitation course. These patients had a significantly poorer quality of life at outset and evidenced a 54% improvement at follow-up compared to a 33% improvement in those who received standard care.


Table III. Comparison of quality of life scores (QLS) at first presentation and follow-up among patients who completed the REACH programme and those who received standard care.

 

 

REACH programme

(N = 19)

t

df

95% CI

Standard care

(N = 77)

t

df

95% CI

QLS Social functioning

5.4

18

(5.6, 10.3)**

6.9

76

(6.5, 14.9)**

QLS Occupational functioning

3.4

18

(3.5, 7.2)**

5.8

76

(2.6, 11.2)*

QLS Intrapsychic foundations

4.1

18

(6.2, 10.5)**

7.8

76

(4.5, 14.0)*

QLS Common objects and activities

3.8

18

(0.5, 1.4)**

4.0

76

(0.7, 2.4)*

QLS total

5.6

18

(17.2, 29.0)**

7.8

76

(18.5, 40.8)**

 


Table IV. Comparison of quality of life scores (QLS) at follow-up between patients who completed the REACH programme and those who received standard care.

 

 

REACH programme

(N = 19)

Standard care

(N = 77)

df

t

P

95% CI

QLS Social functioning

30.2

32.3

94

-0.78

0.44

(-7.48, 3.28)

QLS Occupational functioning

13.3

16.7

94

-2.0

0.052

(-6.83, 0.03)

QLS Intrapsychic foundations

27.5

31.9

94

-1.9

0.07

(-9.17, 0.41)

QLS Common objects and activities

7.5

8.2

94

-1.5

0.148

(-1.74, 0.27)

QLS total

79.7

89.6

94

-1.5

0.14

(-22.96, 3.21)

 

 

We did not have a self-report assessment of quality of life at first presentation for either group of patients. However, at follow-up there was no significant difference between the two groups in terms of their subjective physical health (t = -1.86, P = 0.08), psychological health (t = -0.91, P = 37), social relationships (t = -1.12, P = 0.28) or satisfaction with their environment (t = 0.02, P = 0.99).

 

Psychoeducation

In terms of insight there was no significant difference in recognition of need for treatment (t = 0.76, P = 0.45), ability to relabel symptoms (t = -0.09, P = 0.92), recognition of illness (t = 0.81, P = 0.42) or total insight score (t = 0.57, P = 0.57) between the patients who attended the programme and those who received standard care. They were also indistinguishable in terms of in attitudes to medication (t = -1.19, P = 0.25) and concordance with medication (c2 = 1.38, P = 0.24). Similarly, there was no significant difference in psychopathology (PANSS Positive t = 1.39, P = 0.18; PANSS Negative t = 1.48, P = 0.15; PANSS Total t = 1.63, P = 0.11), GAF score (t = -1.17, P = 0.10)  or the presence of comorbid substance misuse (c2 = 0.42, P = 0.52) between the two groups at follow-up.

 

Hospital admissions and bed days

When we compared the number of hospital admissions and in-patient days between groups we did not include initial hospitalisation data in our analysis as patients were only referred to the programme after assessment by their treating team. Consequently, patients admitted to hospital at the time of their first-episode of psychosis did not commence the REACH programme until they were discharged and including their initial admission data might have biased our results. The group of patients who received standard care evidenced statistically significant fewer hospital admissions (t = 2.98, P = 0.004) and a lower total number of in-patient days (t = 0.004, P = 0.005) compared to those who completed the REACH programme (Figures 1 and 2).


Figure I. Mean number of hospital admissions among patients who completed the REACH programme (N = 19) and those who received standard care (N = 77)

 

Figure II. Mean number of days in hospital among patients who completed the REACH programme and those who received standard care (N = 77)

 

 

 

 

Discussion

The main finding of this study was that patients who attended a psychosocial rehabilitation programme (REACH programme) evidenced a greater improvement in quality of life compared to those who received standard care. Those who undertook the programme had significantly poorer functioning in terms of their quality of life at first presentation especially in the areas of occoupational and social functioning than those who did not undergo the programme. However, after completing the programme their self-report and observer rated quality of life was indistinguishable from those who received standard care. Furthermore, the beneficial effect was maintained for over two years after completion of the programme. The improvement in quality of life among patients who completed the programme reflects the integrative nature of psychosocial rehabilitation programmes (Bachrach, 1992). The environmental focus of such programmes provides patients with the learning and skills necessary for societal integration, which is reflected in improved quality of life at follow-up.

 

The potential benefits of the psychosocial rehabilitation programme may not extend into reduced use of hospital beds as patients who completed the programme evidenced an increased number of readmissions and days spent in hospital at follow-up. A number of factors may explain this. Firstly, patients who completed the programme evidenced poorer functioning at first-presentation and may represent a poorer prognostic group compared to those who received standard care. The use of hospital readmission and bed days could also be criticised as admission rates are influenced by factors independent of clinical condition, such as adequacy of social and family / carer supports, structure of local services and local discharge policies (Ni Nuallain, 1987; Aberg-Wisteldt, 1995). Consequently, differences in admission rates across outcome studies may simply reflect the development of community-based services with different ‘thresholds’ for hospitalisation. Furthermore, psychoeducation was an important component of the REACH programme and patients were informed about signs of relapse and advised to avail of psychiatric services when unwell. 

 

A further reason behind the shortage of research in this area may lie with the increased emphasis on pharmacotherapy in the treatment of schizophrenia. With the advent of newer atypical antipsychotics has come an increase in annual prescription drug expenditures (Kleinke, 2000). Although there is little doubt that these medications are cost-effective (Revicki, 1999; Kleinke, 2000) the recent escalation in medication expenses (Mehl & Santell, 2000) puts a significant strain on mental health care budgets. Consequently, resources for other services, particularly rehabilitation services, are invariably reduced as these resources are directed to pay for these medications (Baker, 2001). Clearly the reduction of these services is problematic for patients suffering from the psychosocial sequelae of chronic mental illness. Paradoxically, the reduction in services may also serve to further escalate medication expenses, as physicians may attempt to treat psychosocial problems with higher doses of medications (Baker, 2001).

 

There are a number of methodological limitations in this study. Firstly, this was an open study and the rater (P.W.) was not blind to whether a patient completed the programme or received standard care. Additionally, patients were not randomised to either arm of the study, as the REACH programme was open to all patients presenting with a first-episode of psychosis. Treating teams made referrals, which raises the possibility of a selection bias as patients who evidenced the greatest functional impairment in terms of their quality of life were more likely to be referred. This is not surprising as the programme was designed to help the more severely affected individuals who did not achieve adequate response from conventional treatments such as antipsychotic medication.  

 

We did not have a formal ‘placebo’ treatment and it could be argued that the improvements noted are due to increased time spent in contact with the services and not the REACH programme per se. However, there are limitations inherent in psychotherapeutic control groups as psychosocial intervention research raises difficult ethical issues in terms of consent, confidentiality, boundary violations and risk-benefit issues (Saks, 2002). Our first-episode study was a best practice study and therefore we were bound by ethical considerations.

 

The modest sample size, especially in the intervention group, is a further limitation. This was the result of limiting our sample to cases presenting with a first-episode of psychosis. All patients were diagnosed by using the Structured Clinical Interview for DSM-IV (SCID 1 Interview) rather than case note review and included patients never admitted to an in-patient facility. Even though the sample size increases the risk of a type II error we were nevertheless able to control for potential confounding factors such as variable durations of illness and treatment.

 

 

Conclusion

 Even though pharmacological treatment reduces psychopathology among patients with psychosis, it does not appear to have a positive impact on a client’s living skills unless it is combined with rehabilitation interventions (Attkisson, 1992). The effectiveness of such intervention has often been questioned and research has been hampered by, amongst other things, patient selection with previous studies drawing on patients at different stages of illness with different durations of treatment. This study supports the use of psychosocial interventions for patients recovering from psychosis. However, the potential benefits of such interventions may not extend into reduced use of hospital beds. The field of psychosocial rehabilitation has been forced out on a limb and has tended to become an isolated and viewed as a separate treatment for patients with psychosis. Clinician biases and lack of adequate training are some of the reasons for this (Bachrach, 1996). If we are to offer the most effective treatments to our patients then we must address these issues and view psychosocial treatments as integral parts of treatment for the major psychoses.

 

 

References

  
Aberg-Wistedt, A., Cressell, T., Lidberg, Y., Liljenberg, B. & Osby, U. (1995). Two-year outcome of team-based intensive case management for patients with schizophrenia. Psychiatric Services, 46(12), 1263-1266.
 
Adams, S. G., & Howe, J. T. (1993). Predicting medication compliance in a psychotic population. Journal of Nervous and Mental Disease, 181, 558-560.

American Psychiatric Association (1994).  Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM-IV), Washington, DC: APA.  
 
Anthony, W. A., Cohen, M. R. & Danley, K. S. (1988). The psychiatric rehabilitation approach as applied to vocational rehabilitation. In J. A. Ciardiello (Ed.), Vocational Rehabilitation of Persons with Prolonged Psychiatric Disorders (pp. 224-248). Baltimore: Johns Hopkins University Press.  
 
Attkisson, C., Cook, J., Karno, M., Lehman, A., McGlashan, T. H., Meltzer, H. Y., O’Connor, M. et al. (1992). Clinical Services Research.  Schizophrenia Bulletin, 18(4), 561-626.

Bachrach, L. L. (1992). Psychosocial rehabilitation and psychiatry in the care of long-term patients. American Journal of Psychiatry, 149(11), 1455 –1463.

Bachrach, L. L. (1996). Psychosocial rehabilitation and psychiatry: what are the boundaries. Canadian Journal of Psychiatry, 41(1), 28 – 35.

Bachrach, L. L. (2000). Psychosocial rehabilitation and psychiatry in the treatment of schizophrenia – what are the boundaries. Acta Psychiatrica Scandinavica, 407 (Suppl), 6-10.

Baker, J. G. (2001). Engaging community mental health stakeholders in pharmacy cost management. Psychiatric Services, 52(5), 650-653.

Birchwood, M., Smith, J., Drury, V., Healy, J., Macmillan, F. & Slade, M. (1994). A self-report insight scale for psychosis: reliabiltiy, validity and sensitivity to change. Acta PsychiatricaScandinavica, 89(1), 62-67. 

Browne, S., Clarke, M., Gervin, M., Waddington, J. L., Larkin, C. & O'Callaghan, E. (2000). Determinants of quality of life at first presentation with schizophrenia. British Journal of Psychiatry, 176, 173-176. 

Frangou, S., & Murray, R. M. (2000). Psychosocial interventions. In S. Fangou (Ed.),  Schizophrernia (pp. 61-65). London: Dunitz.
 
Heinrichs, D. W., Hanlon, E. T. & Carpenter, W. T. (1984). The Quality of life scale: an instrument for rating the schizophrenic deficit syndrome. Schizophrenia Bulletin, 10(3), 388-398. 

Hogan, T. P., Awad, A. G. & Eastwood, R. (1983). A self report scale predictive of drug compliance in schizophrenics: reliability and discriminative validity. Psychological Medicine, 13, 177-83. 

Huxley, N. A., Rendall, M. & Sederer, M. (2000). Psychosocial treatments in schizophrenia. A review of the past 20 years. Journal of Nervous and Mental Disease, 188, 187-201.  

Kay, S. R., Fiszbein, A. & Opler, L. A. (1987). The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophrenia Bulletin 13, 261-276. 

Kane, J., Honigfeld, G., Singer, J. & Meltzer, H. (1988). Clozapine for the treatment-resistant schizophrenic. A double-blind comparison with chlorpromazine. Archives of General Psychiatry, 45, 789-796.
 

Kleinke, J. (2000). Just what the HMO ordered: the paradox of increasing drug costs. Health Affairs, 19, 78-91.

Lee, A. S., & Murray, R. M. (1988). The Long term outcome of Maudsley depressives. British Journal of Psychiatry, 153, 741-751. 

Mehl, B., & Santell, J. (2000). Projecting future drug expenditures - 2000. American Journal of Health-System Pharmacy, 57, 129-138. 

Ni Nuallain, M., O’Hare, A. & Walsh, D. (1987). Incidence of schizophrenia in Ireland. Psychological Medicine, 17, 743-748.
 
Ohmori, T., Ito, K., Abekawa, T. & Koyama, T. (1999). Psychotic relapse and maintenance therapy in paranoid schizophrenia: a 15 year follow up. European Archives of Psychiatry and Clinical Neurosciences, 249, 73-78.
 
Revicki, D. (1999). Pharmacoeconomic studies of atypical antipsychotic drugs for the treatment of schizophrenia. Schizophrenia Research (Suppl), 35, 101-109.
 
Robinson, D., Woerner, M. G., Alvir, J. M. Bilder, R., Goldman, R., Giesler S., Koreen, A., Sheitman, B., Chakos, M., Mayerhoff, D. & Lieberman, JA. (1999). Predictors of relapse following response from a first episode of schizophrenia or schizoaffective disorder. Archives of General Psychiatry, 56, 241-7. 

Saks, E. R., Jeste, D. V., Granholm, B. W., Palmer, B. W. & Schneiderman, L. (2002). Ethical issues in psychosocial interventions research involving controls. Ethics and Behaviour, 12, 87-101. 

Shepherd, M., Watt, D., Falloon, I. & Smeeton, N. (1989). The natural history of schizophrenia: a five-year follow-up study of outcome and prediction in a representative sample of schizophrenics. Psychological Medicine. Monograph Supplement, 15, 1-46. 

Spitzer, R. L., Williams, J. B., Gibbon, M. & First, M. B. (1995). Structured Clinical Interview for DSM-IV- patient Edition (SCID-P). Washington DC: American Psychiatric Press. SPSS Inc. (2001). Release 11.0.1. Statistical Package for the Social Sciences for Windows. Chicago, IL, USA.
 
Wiersma, D., Nienhuis, F. J., Sloof, C. J. & Giel, R. (1998). Natural course of schizophrenic disorders: a 15 year follow up of a Dutch incidence cohort. Schizophrenia Bulletin, 24, 75-85.  
 
WHOQoL Group. (1998). Development of the World Health Organistation WHOQoL- BREF quality of life assessment. Psychological Medicine, 28, 551-558.

 




Copyright © 2006 Hampstead Psychological Associates, Ltd - A Subsidiary of Southern Development Group, SA.
All Rights Reserved.   A Private Non-Profit Agency for the good of all, published in the UK & Honduras