The International Journal of Psychosocial Rehabilitation

Rehabilitation for students diagnosed with depression and/or anxiety disorder - feasibility and perceived impact of OPI group rehabilitation program in Finland
 
Kaija Appelqvist-Schmidlechner
Senior researcher, Ph.D
National Institute for Health and Welfare
Mental Health Unit
P.O. Box 30, FI-00271 Helsinki, Finland
kaija.appelqvist@thl.fi
 
Jenni Wessman
Researcher, M.soc.Sc
National Institute for Health and Welfare
Equality and Inclusion Unit
P.O. Box 30, FI-00271 Helsinki, Finland
jenni.wessman@thl.fi
 
Ulla Salmelainen
Senior researcher, Ph.D
National Institute for Health and Welfare
Ageing, Disability and Functioning Unit
P.O. Box 30, FI-00271 Helsinki, Finland
ulla.salmelainen@thl.fi
 
Annamari Tuulio-Henriksson
Research professor, Ph.D
Social Insurance Institution
Research department
PL 450, 00250 Helsinki, Finland
annamari.tuulio-henriksson@kela.fi
 
Minna-Liisa Luoma
Research manager, Ph.D
National Institute for Health and Welfare
Ageing, Disability and Functioning Unit
P.O. Box 30, FI-00271 Helsinki, Finland
minna-liisa.luoma@thl.fi
 
Corresponding author:
Kaija Appelqvist-Schmidlechner
Senior researcher, Ph.D
National Institute for Health and Welfare
P.O. Box 30, FI-00271 Helsinki, Finland
kaija.appelqvist@thl.fi

 
 
Conflicts of interest: The authors declare that they have no conflict of interest.
Funding: The study was funded by the Social Insurance Institution of Finland

 


Citation:
Appelqvist-Schmidlechner A, Wessman J, Salmelainen U, Tuulio-Henriksson A & Luoma M.  (2015)  Rehabilitation for students
diagnosed with depression and/or anxiety disorder - feasibility and perceived impact of OPI group rehabilitation program in Finland.
  International Journal of Psychosocial Rehabilitation. Vol 19(1) 119-126



Abstract
The OPI mental health rehabilitation program is a new form of outpatient group rehabilitation for adolescents and young adults aged 16−25 years studying in vocational schools and diagnosed with mood or anxiety disorders. This study aimed at investigating the feasibility and perceived impact of the program on participants’ learning and functional capacities, quality of life and severity of depression.
The data (n=70) were collected using questionnaires and with focus group interviews. Quality of life was measured with the Eurohis-8 scale, severity of depression with RBDI.
Quality of life and learning capacities were increased and severity of depression was reduced among participants during the rehabilitation. Positive outcomes were associated with timely occurrence of the rehabilitation, co-operation with the mental health service responsible for the treatment during the program and with well-functioning interaction between client and counsellor. Peer support was experienced as the most remarkable benefit of the program among participants.

KEY WORDS: supported education, depression, anxiety, young people, recovery


Introduction:
Young people with mental health problems experience barriers to entering, maintaining and completing education (Kessler et al. 1995). Mental disorders affect student's motivation, concentration and ability to appropriately engage in social interactions which are all critical factor in academic success (Padron 2006). There is a need for increased understanding and support of students with psychiatric disorders. This kind of achievement is important not only for prevention of social exclusion among young people with mental health problems but also for recovery. Education can be seen as an important factor in the process of recovery (Mansbach-Kleinfeld et al. 2007).

To support students with mental health problems, supported education programmes are undertaken, commonly in partnership between variety of stakeholders: public mental health services, families, education institutions and rehabilitation agencies (Mowbray et al. 2005; Best et al. 2008). The purpose of supported education is to increase the ability of people with psychiatric disabilities to access and participate in post-secondary education by providing necessary support (Unger 1990). There is a variety of different models among these programmes but only limited evidence of effectiveness of this kind of programmes (Mowbray et al. 2005; Rogers et al. 2010).

Depression is the most common mental disorder among young people and one of the major causes of work disability, too (Alonso et al. 2011; Bruffaerts et al. 2012). In Finland, increased number of premature work disability retirements among young people due to depression disorder has raised concerns (Raitasalo and Maaniemi 2011). As a contribution to support working capability of young people, the Social Insurance Institution of Finland (Kela) has recently focused on developing and funding rehabilitation programs targeted at young people with psychiatric disorders and/or risk for social exclusion. One of these newly developed programs is the OPI rehabilitation program targeted at young people aged of 16−25 years who are studying in vocational schools and are diagnosed with depression and/or anxiety disorder.

OPI enables students with depression and/or anxiety disorder to attend rehabilitation alongside vocational education. The program aims at supporting participants in their studies, teaching coping skills and promoting their general well-being. Cooperation between rehabilitation service provider and school create a foundation for the program. 

The aim of the study was to investigate the feasibility and perceived impact of the OPI rehabilitation program on participants' learning and functional capacities, quality of life and severity of depression. 

Materials and methods
OPI
OPI is a group based rehabilitation course for students diagnosed with depression and/or anxiety disorder. The length of each rehabilitation course is 18 months including a follow up period of 6 months. The participants are able to participate in the program alongside vocational school during school semesters. During 2011−2013, eight courses were undertaken by two rehabilitation service providers in Finland. Each course had up to 12 participants. Referrals to the program were made by the school health service, school social worker or community health services. The courses were led by two counselors (psychologist/psychiatric nurse and social psychologist/social worker).

OPI consisted of group sessions (6 x 3 days) and six one-to-one sessions. It was also possible to invite e.g. the school social worker, parents or other relevant people to take part in some of the one-to-one sessions. Commonly, the school social worker acted as a link between the school and service provider, launching and maintaining dialog and consultation between these two parties, in collaboration with the client.

The program manual gave the guidelines in executing the program. The program was based on cognitive-behavioral, solution-focused approach. The topics for group sessions were most commonly the following: negative thought stopping, relaxation, cognitive-behavioral therapy techniques and practical exercises, self esteem, stress management strategies, relapse and early warning signs.

Methods
The study design included pre- and post tests among participants, process evaluation and focus group interviews. Altogether 80 students participated in the program and of these, 70 participated in the study.

Data were gathered with questionnaires among participants at three different points in time: at baseline (n=69), in 12 months (n=59) and in18 months (n=56). Quality of life was measured with the Eurohis-QOL-8-item index (Power 2003) and severity of depression with the short form of the Beck Depression Inventory (RBDI). RBDI has 13 questions for depression and one for anxiety (Raitasalo 2007). The depression score can range from zero to 39 points. Five to seven points refer to mild depression, eight to fifteen points to moderate depression, and over sixteen points to severe depression. Learning capacities were investigated with 12 questions used earlier in the Finnish School Health Promotion Study (http://www.thl.fi/fi/web/thlfi-en/research-and-expertwork/population-studies/school-health-promotion-study). Sum score of learning capacities ranging from 12 to 48 was calculated, higher scores indicating more problems with learning. The questionnaires included also a question about self-rated health with a scale 0-10, higher rates indicating better state of health. 

In the process evaluation, data about each program participant were gathered from counselors using questionnaires including questions about the commitment (amount of non-attendance) and progress of each participant, interaction between counsellor and client (easygoing, confidential, open, reciprocal; scale 1=not at all, 2=only a little, 3=some, 4=pretty and 5=very), co-operation with the health care service responsible for the treatment (yes/no), and if the rehabilitation occurred at the right time considering the state of health of the client (strongly agree/ agree/neutral/ disagree/strongly disagree), among others. Further, the counsellors were asked to assess the impact of rehabilitation on learning capacities and psychological symptoms of the client (Scale 1=not at all, 2=some, 3=quite strong, 4=very strong, 5= can not say).

In the end of each course, focus group interviews (Krueger & Casey 2000) were conducted among program participants by two researchers. In the interviews, themes like experiences on participating in the program as well as perceived benefits and feasibility of the program were discussed. The length of the interviews were from 40 minutes to 2 hours. Altogether 47 students participated in the interviews (38 females and 9 males)

Data analysis
Descriptive statistics were used to report the data. Paired t-tests were used to determine whether there were any differences between baseline and follow-up measures. Linear mixed models were used to test if certain variables (gender, age, attendance, co-operation with health care service, severity of depression) were associated with these changes. In the process evaluation data, variables were dichotomized and analysed with Chi-square for testing if the co-operation with the health care service (yes vs. no), positive interaction between counsellor and client (strongly agree vs. other alternatives) and timely occurrence of rehabilitation (strongly agree vs. other alternatives) were associated with positive outcomes of rehabilitation (at least quite strong positive impact vs. less impact) assessed by the counsellors. Statistical analyses were performed using the PASW Statistics 18.0 program. The level of significance was set at 0.05.

Focus group interviews were recorded with the permission of the respondents and transcribed. The length of recording was 9 hours and 25 minutes (transcribed in 159 pages, single line spacing, Times New Roman 12). The data was analysed using content analysis.

Ethical approval for the study was granted by the ethics committee of The Hospital District of Helsinki and Uusimaa and the National Institute for Health and Welfare.

Participants
All study participants (n=70, 81 % females and 19 % males) were students in two different vocational schools in Finland (16-29 years, mean age 19), all with diagnosed depression and/or anxiety disorder. According to RBDI at baseline, 26 percent of them had severe, 48 percent moderate, 12 percent mild and 14 percent minimal depression. At baseline, 66 per cent of them had serious difficulties in preparing for the exams and 62 per cent in doing homework. Almost half of participants (48 %) were referred to the program by the school health service, 28 per cent by community health services and 22 per cent by school social worker.

Results
During the rehabilitation, severity of depression was reduced and quality of life, learning capacities as well as self-rated health were improved among study participants (Table 1). Changes in time were not associated with gender, age, severity of depression at baseline, use of other mental health services during the rehabilitation or participants' commitment and attendance in the program.

Table 1. Learning capacities (total score), quality of life (Eurohis-QOL-8) and severity of depression (RBDI) at baseline, after 12 months and after 18 months

 

n

Mean

p-value1

Sum score of learning capacities

Baseline

After 12 months

After 18 months

 

65

54

42

 

2,49

2,54

2,05

 

 

 

p <.001, t = 4,727, df = 38

Eurohis-QOL-8

Baseline

After 12 months

After 18 months

 

68

59

52

 

2,77

2,77

3,11

 

 

 

p=.001, t=-3.681, df=50

RBDI

Baseline

After 12 months

After 18 months

 

66

60

53

 

12,48

11,42

8,55

 

 

 

p = .001, t = 3,530, df = 49

Self-rated health (0-10)

Baseline

After 12 months

After 18 months

 

69

59

56

 

4,81

5,37

6,21

 

 

 

p < .001, t = -4,510, df = 44

1 Paired t-tests between baseline and after 18 months

Among the participants, 87 per cent were at least moderately satisfied with the program and 73 per cent felt that they had achieved their goals set for the program, particularly those, who felt the program occurred at the right time (p=.041).

According to the assessments of the counsellors, 63 per cent of participants would have needed rehabilitation already at earlier stage. Among 68 per cent, symptoms were reduced and among 59 per cent learning capacities improved during the rehabilitation assessed by the counsellors. Assessments of improved learning capacities were associated with timely occurrence of the rehabilitation (p=.017). Assessments of reduced symptoms were associated with timely occurrence of the rehabilitation (p=.009), co-operation with the mental health service responsible for the treatment during the program (p=.006) as well as with easygoing (p=.036) and reciprocal (p=.011) interaction between the client and counsellor.

Results from the focus group interviews among participants indicated several benefits of the program. Peer support was seen as one of the most important benefits of the program. In group sessions with peers, students had the possibility to talk with other in similar conditions. It was a relief for many to realize that other experience the same problems and are struggling, too. Group sessions offered the possibility to talk about serious matters, but also to laugh together.

"It’s so cool that even if we talk about rough things and cry together and something like that, but after a coffee break we can have fun and laugh together. I mean, you don’t have to be sad all day, even if you have just handled very deep stuff and talked about rough issues."

Participants reported improved learning capacities and empowerment.. Non-attendance from the school was reduced among program participants and for some students dropping out the school could have been prevented due to the program. Further, skills and capacities to manage daily life were improved. OPI gave the schedule for the day and the reason to stand up in the morning

”I don't know how this has affected my mood but just to come here and when I'm in this group... when I come here, I actually have a good day. It keeps me going. I have something else to do than just sitting at home."

Further, participants reported improved mental health literacy. Knowledge about mental illness, its symptoms and early warn signs was increased. Seeking help and telling other about problems had become easier. Self-stigma was reduced.

OPI had a positive impact also in social skills. Acting in social situations with other people in school or elsewhere had become easier.

”These group sessions have been beneficial, as I have had problems specifically with social situations. The sessions had make me stronger and it is much easier for me to be myself in groups."

Positive atmosphere and progress in recovery enhanced self-esteem. For many students, rehabilitation offered, among other things, also a possibility to take a breath in the middle of school stress.

Discussion
The findings of this study suggest that OPI is a feasible, acceptable and beneficial program in supporting students with depression and/or anxiety disorder. Peer support through group-based rehabilitation seemed to be one of the most important benefits of the OPI.

Group work has been recommended as an effective intervention in various settings to address mental health (Matsunaga et al. 2010), also among young people (Sommers-Flanagan et al. 2000; Paone et al. 2008). In line with previous results (Newbold et al. 2013), this study showed that group-based interventions have the possibility to relieve symptoms of depression by lessening the stigma of mental illness and by increasing social contact. OPI participants felt understood and connected with each other by having the diagnosis of depression, which reduced their feelings of isolation and "otherness". In group-based rehabilitation programs participants have the possibility to hear about strategies experienced useful by the others and observe others' progress, which may bring hope for their own recovery. For many, it may be easier to accept new practices and techniques to cope from peers than from a health care professional.

Besides peer support, the benefits of group work can be obtained in enhancing communication skills and in expanding participants' ability to view issues from others' perspectives, similar to the study of Paone et al. (2008). Structured groups provide a safe environment to learn and practice new skills (Sommers-Flanagan et al. 2008).

Group-based programs do not necessarily suit for everyone. Group work can be stressful and overwhelming for some. Some participants had concerns about group work and they didn't want to participate in the OPI program or they dropped out after the first session. However, OPI allowed "silent participation", too. Some participants did not want to contribute in the group discussion but they still had the opportunity to hear the perspectives and views of those who did. This opportunity for “silent participation” was experienced as important among program participants.

Group interactions were not always experienced as positive.  Sometimes some participants took more opportunity to talk than others. It is important to keep the number of participants small enough so that all have the opportunity to contribute. Further, the role of the counsellor in directing the discussion is of crucial importance. 

Similar to previous study (Newbold et al. 2013), the findings suggest that a rehabilitation program like OPI has the possibility to facilitate participants recovery through social factors such as group belonging, support and acceptance, guidance and normalisation. The study also showed that most of the students had a need for support already at an earlier stage. Timely occurrence of the rehabilitation was associated with positive outcomes assessed by the counsellors. Further, co-operation with the mental health services responsible for the treatment and well-functioning communication between the client and counsellor played an important role in the progress of the participants. 

Group-based programs have been suggested as a lower cost, less time-demanding alternative to individual treatment (McCrone et al. 2005; Johnson 2012). However, it is important that participants seeking for rehabilitation are screened for inclusion before the groups are formed. In this way, participants most likely to respond to group-based approaches and least likely to suffer adverse effects from this kind of setting are identified. Further, it is important to guarantee that individual sessions are available for those who require them. In OPI, one-to-one sessions were included in the program. This possibility was seen as important among participants

Collaboration with the school - particularly with school social worker and school health service - played an important role in the OPI program. Besides screening for potential participants, they served as a link between the school and rehabilitation providing dialog and consultation between these two parties, in collaboration with the client. Furthermore, it is important that the rehabilitation course fits into the rhythm of the school day.

A weakness of the study design was the lack of a control condition.  The observed changes cannot exclusively be attributed to the intervention. However, positive impacts of the program became quite clear in the focus group interviews. A notable strength of the study was the use of mixed methods collecting quantitative as well qualitative data.

OPI seems to be beneficial and feasible program which can be applied in preventing the marginalization of young people with mental health problems. It represents an innovative approach of co-operation between mental health services and school system in Finland. So far, the results and experiences of this group-based program and its perceived impact are promising. The Social Insurance Institution of Finland will establish and disseminate the program in whole country.
 



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