Psychosocial Rehabilitation Program for Schizophrenia Disorder Patients: Measuring Disease Impacts and Intervention Outcomes

ARTICLES and ISSUES | PJP 2020 Combined Issue

Sally Bongalonta, MA ,
Marivic V. Briguela, MD,
Amor Mia H. Arandia, MA, MDiv,
Domingo R. Rayco, Jr., PhD ,
Jeremaine W. Prieto, BS , &
Lina B. Laigo, PhD

Published: January 2020
DOI

Sally Bongalonta, MA (Institute of Family Life, Children & Women Studies, Philippine Women’s University); Marivic V. Briguela, MD (Cavite Center for Mental Health); Amor Mia H. Arandia, MA (Jose Rizal University & UST-GS Psychotrauma Clinic); Domingo R. Rayco, Jr., PhD(Philippine Women’s University – Manila); Jeremaine W. Prieto, BS (UP-Philippine General Hospital); & Lina B. Laigo, PhD (Institute of Family Life, Children & Women Studies, PWU) *Research previously presented in the 55th Annual Convention of Psychological Association of the Philippines at the Philippine International Convention Center (PICC) Manila on September 20-22, 2018 by Amor Mia Arandia & Domingo Rayco Jr.; Corresponding Author email address: amormia.arandia@jru.edu

ABSTRACT

OBJECTIVES: This study purposed to measure the effectiveness of the Psychosocial Rehabilitation (PSR) Program, which was a combination of occupational therapy and psychoeducation in managing patients diagnosed with schizophrenia who were recovering in a mental health facility as well as identify gaps and problems in its implementation. METHODOLOGY: An experimental design was used followed by a qualitative study to further analyze the impacts of the psychosocial rehabilitation program. RESULTS: Pre-and-post-test measures showed that clinical global improvement, psychiatric symptoms and socio-occupational functioning of the patients improved while quality of life and enjoyment did not change. Performance and satisfaction of experimental group participants related to the occupational therapy program also increased. Insights and meaningful realizations were observed in those who had undergone the psychosocial rehabilitation program (PSR). CONCLUSION: Implications for treatment and recommendations for the psychosocial program were made to address challenges in implementing the psychosocial rehabilitation program.

KEY WORDS: psychosocial rehabilitation program, occupational therapy, psychoeducation program, clinical global improvement, socio-occupational functioning

INTRODUCTION

Schizophrenia is a chronic condition with significant physical and mental effects that may result in disabilities (1) in areas like body structure and social functioning.  (2)  It is the most frequent diagnosed mental disorder next to substance abuse among Filipinos. (2) As such, individuals diagnosed with the disorder need rehabilitation so they can be reintegrated in society. (3)

Towards this end, mental health practitioners use the PSR Program, a “program for persons with long-term mental illness that will provide social, occupational, leisure and living skills to assist them in living as independently as possible”. (4)  The program is the most effective treatment modality for people with mental illness to facilitate change, hope and recovery by focusing on the person and not their illness. (5) A meta-analytic review shows that psychosocial rehabilitation services are aimed at long-term recovery designed to optimize self-sufficiency as distinguished from stabilization of symptoms in acute care. (6) More so, psychosocial (PS) interventions need to become a major part of the standard treatment of the disease. (7) In the past several decades PSR has gained a vast following as a major service modality in the treatment and care of people who suffer from Schizophrenia. (8)

The PSR program provides activities that target social, occupational, psychological, leisure and living skills. The combination of pharmacotherapy with PSR is considered to be the best type of treatment for schizophrenic patients. (9)

Community-based PSR programs were compared in low income countries like Nigeria, India and the Philippines. (10) The Philippine PSR program at the Holy Face Rehabilitation Center for Mental Health in Tabaco City, Albay showed that patients who attended more sessions regularly had lesser relapses. However, up to now, there is still a dearth of studies in the country documenting the impact of PSR on schizophrenia patients, thus this study was conducted.

Aware of the positive effects of the PSR program as cited by many countries, but its efficacy not yet well documented in the Philippines , the researchers sought to test out its effectiveness for patients diagnosed with schizophrenia as well as identify its treatment gaps.

OBJECTIVES

This study aimed to determine the effectiveness of a four-month PSR program – composed of occupational therapy and psychoeducation program – for schizophrenic patients. The Specific Objectives were to:

  1. determine the effectiveness of the PSR program in reducing psychiatric symptoms and improving  the socio-occupational functioning of schizophrenic patients.
  2. identify possible gaps and problems in the program implementation.

METHODOLOGY

Research Design

The combined experimental and qualitative designs were used. The experimental condition involved the delivery of seven psychoeducational sessions for patients together with at least one family member or relative in attendance and fourteen occupational therapy sessions for the patients, as adjunct to pharmacotherapy and standard consultations.  The control group continued to receive the usual standard care of pharmacotherapy and consultations with the hospital’s psychiatrists. Afterwards, a qualitative study was conducted in order to further analyze the social validity and clinical significance of the findings.

Setting

The study was conducted at a government mental health facility in Region IV-A in the Philippines i.e. Cavite Center for Mental Health (CCMH) housing around a hundred female and male patients with various mental illnesses using psycho-pharmacotherapy and supportive psychotherapy. Psychoeducation was being given irregularly and occupational therapy was on hold due to unavailability of trained personnel. The patients followed a structured routine administered by psychiatric nurses, psychiatrists, a psychologist and support staff.

Participants of the Study

The inclusion criteria were: patients diagnosed with schizophrenia based on DSM-5 criteria (11), aged 18 to 59 years old, Filipino, confined at a government facility but already fit to undergo PSR as evaluated by their attending psychiatrist to have a level of understanding sufficient to give consent to the required tests and examinations as well as determine their readiness for the PSR activities. The exclusion criteria were those: in the acute phase of psychosis i.e. had current delusions, hallucinations and/or disorganized behaviors; with communication difficulties; not recommended by their attending psychiatrists; and without family members who could come to attend the sessions.

All participants and their family members or caregivers were asked to sign an Informed Consent.

For this study, the Cohen’s d formula [d = M1 – M2 / spooled] was used in estimating the sample size. (12) The Cohen’s d effect size formula was used for an experimental and control group study that were of equal size. It computed for the .50 effect size of power and the desired significance level was 0.05. It determined the expected difference between the means of the target values between the experimental and the control groups, divided by the expected standard deviation.

The estimated computed sample was 64 (n) but researchers gathered up to 70 participants to replace for possible attrition. Out of 70 participants that were initially included in the study, only 65 remained. Two of the respondents in the experimental group were dropped due to medical conditions, while another one was dropped because he showed bipolar symptoms.

The fishbowl random sampling technique was used with odd numbered participants assigned to the experimental group and even numbered ones to the control group.

The experimental condition involved the delivery of 7 psychoeducational sessions for schizophrenic patients together with at least one family member or relative, 14 occupational therapy sessions, as adjunct to the usual pharmacotherapy and consultations; while the control group was given merely the usual standard care of pharmacotherapy and consultations with the hospital’s psychiatrists.

Comparison of pre-test and post-test scores on measures of psychiatric symptoms, global improvement, quality of life and socio-occupational functioning were done. Also computed were observed psychiatric symptoms and evaluation results of the psychoeducation and occupation therapy programs throughout the intervention phase to determine if there were changes in behavior. Correlation statistics were computed for socio-demographic variables of age, gender and length of confinement, length of illness and frequency of admissions as well as other variables measured in the study.

After the PSR program, purposive sampling was used for the qualitative portion of the study. Eight participants out of 10 were interviewed since 2 were invalidated due to lack of proper disposition. The interview determined their views on the outcome of the sessions and identified its impact on their lives. These participants were recommended by the Nurse in-charge and the Occupational Therapists as those with better functioning, less symptoms, able to express themselves, and had undergone at least 80% of the PSR program. A semi-structured interview questionnaire in Filipino was used by two Psychologist interviewers (one main and one assistant); after  the questionnaire was content validated by three professors of Psychology. The participants expressed willingness to be interviewed and agreed to being recorded.

Instruments

With their authors’ permission, the research used the following data gathering tools:

1. The Background Information Sheet which gathered personal information like name (optional), age, gender, length of stay in the mental health facility and diagnosis with the help and validation of the hospital staff.

2. The Clinical Global Impression (CGI) Scales is a widely used psychiatric brief global measure of symptom severity and treatment response and efficacy, that employs a 3-item observer rated scale to describe illness severity (CGI-S) and global improvement (CGI-I). (13) The CGI-S uses a symptom severity 7-point scale, ranging from 1 (normal) to 7 (amongst the most severely ill patients), while the CGI-I ranges from (very much improved) to 7 (very much worse). Responses to treatment were rated based on therapeutic efficacy and treatment related adverse events; with a range from 0 (marked improvement and no side-effects) to 4 (unchanged or worse and side-effects outweigh the therapeutic effects). The components of CGI-I were rated separately and the instrument did not yield a global score. However, for this study, the researchers did not use the therapeutic response and effect since they were not interested in the medication component of the test.

3. The Brief Psychiatric Rating Scale (BPRS) is a standard rating scale that a clinician may use to measure the severity of specific psychiatric symptoms. (14) These psychiatric symptoms include: somatic concern, anxiety, emotional withdrawal, conceptual disorganization, guilt feelings, tension, mannerisms and posturing, grandiosity, depressive mood, hostility, suspiciousness, hallucinatory behavior, motor retardation, uncooperativeness, unusual thought content, blunted affect, excitement and disorientation. The severity of each symptom was rated from 1 (not present) to 7 (extremely severe). It yielded a total subscale score and one total psychopathology score. The BPRS provided a pretest, in-treatment evaluation and posttest measures.

4. The Filipino Translation of the Short Form of Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q SF) (15) is a brief 16-item derivative of Quality of Life Enjoyment and Satisfaction Questionnaire retaining the same general activities content (16), measuring the subjective view of the client covering the physical, psychological and social domains of daily life. (17) The questionnaire was translated to Filipino, having undergone translation by a Filipino professor, then back-translated by an English professor and content validated by three Psychologists.

5. The Canadian Occupational Performance Measure (COPM) (18) is a semi-structured client-centered interview designed for Occupational Therapy (OT) clients to: (a) identify concerns regarding their performance during self-care, productivity, and leisure activities; (b) assess their own performance and satisfaction in relation to self-identified problematic occupational performance areas; and (c) prioritize problems in occupational performance in order to determine areas to focus on during intervention. It asked patients what OT activities they found easy and/or satisfying from a low 1 (not able to do/not satisfied at all) to a high 10 (able to do extremely well/extremely satisfied) that covered the following areas: self-care and personal care as well as functional mobility, community management, productivity, handling paid/unpaid work, household management, play/school skills, leisure, quiet recreation, active recreation and socialization.

To calculate the score, the problem ratings were summed and divided by the number of problems prioritized, giving the mean score. The mean COPM core ranged from 1 to 10. (19) Although self-administered, to ensure validity, the Occupational Therapist and his/her assistant assisted the patients in answering the questionnaire. (18)

6. The Occupational Therapy Task Observation Scale (OTTOS) was developed to facilitate evaluation and documentation of patient’s progress in performance during occupational therapy task groups in a multi-disciplinary team. It is a valid and reliable quantitative OT monitoring tool composed of 10 items to evaluate specific task functions and 5 items for general behavior.  (20)

7. Pagsusuri sa Sesyon ng OT (PSOT) was aresearcher-made and expert-validated questionnaire in Filipino created in 2017 for this study by Prieto (one of the authors who is a Registered Occupational Therapist). The 3 OT experts face or content validated the questionnaire by looking into its agreement or consistency to evaluate the items of the questionnaire i.e. do the items in the questionnaire estimate or measure what they were actually designed to measure and how useful are the items for the population, on which it will be used. Those items in the test, which were accepted by all 3 experts were the items included in the questionnaire. (21)  It measured the knowledge gained and impact of OT sessions on the participants with items covering (a) clarity of objectives, instructions, and procedures, (b) patient evaluation of his/her performance, (c) appropriateness of time to complete the session, (d) usefulness of the lesson, and (e) desire to continue OT sessions. The test has 5 items and was answered from 1-5 responses (from 1=strongly disagree to 5=strongly agree) with some assistance from the nursing attendant i.e. reading the questions for them and ensuring patients didn’t confer or copy from one another.

8. Pagsusuri sa Sesyon ng Psychoeducation (PSP) was a researcher-made tool in Filipino created by Rayco in 2017 for this study (one of the authors who is a Registered Psychologist). This was face or content validated by 3 experts in psychology and only those items accepted by all 3 were included in the tool in similar fashion as with the PSOT.  (21)  It is composed of five simple “oo” o “hindi” (“yes” or “no”) pre- and posttest questions per session to measure the knowledge of the patients and their family members in attendance on the topic on hand. Patients were also assisted in accomplishing this in the same manner as in completing the PSOT.

9. The Interview Guide Questionnaire (IGQ) was also a researcher-made qualitative semi-structured interview instrument in Filipino created by Arandia in 2017 (one of the authors, a Psychologist-Researcher).  It was only face or content validated by Psychoeducation Program Head, Senior Researcher and Research Consultant prior to application in a similar process as with PSOT & PSP. (21)  It was used to draw out the patients’ thoughts and feelings regarding the PSR program, views on the recovery process, social relations within and outside the mental health facility, and of the world, using the principles outlined by Brinkman and Kvale in 2009 in the design and conduct of semi-structured interviews. It was administered after the program spanning one month. (22)

Data Gathering Procedures

The participants and their family members who fulfilled the inclusion criteria voluntarily signed an Informed Consent Form, which included the rationale for the study and their freedom to withdraw at any time. A pre-test was conducted prior to the implementation of the intervention  program.  

Participating Psychiatrists were trained by the Chief Psychiatrist in the use of the CGI and BPRS assessments for initial screening. The research assistants were trained by the Senior Researcher and Psychologist in conducting assessments to the patients. Two Registered Occupational Therapists  (OT-A and OT-B) were trained in using the COPM (OTs’ rating) and Pagsusuri ng OT Sesyon (patients’ self-rating) (OT A and OT B) who assisted the participants to ensure validity of responses.

Psychosocial Rehabilitation (PSR) Program

The PSR Program was a combination of Occupational Therapy and Psychoeducational sessions simultaneously done with their other specific schedules.

For this study, the researchers adapted the Philippine Mental Health Association (PMHA) Psychoeducation Model with supporting sources from the World Association for Psychosocial Rehabilitation (WAPR) and the Mood Harmony Support Group at the Makati Medical Center simplifying them as much as possible for schizophrenic patients in the study site. The one-and-a-half hour (1.5 HR) sessions tackled topics supportive of recovery conducted  in Filipino by invited guest resource  persons (from the fields of Psychiatry, Psychology, Nutrition, and  Occupational Therapy) on a bi-monthly basis on patients and  their family members for four consecutive months inside the social hall of the facility. The whole research team helped  in the implementation, assisted by the resident psychiatric nurse.

A simple five-item true or false pretest-posttest measure in Filipino was administered to the patients and their family members separately per session in 2 different locations of the government facility to avoid collusion among them (with assistance from the research team to ensure they understood the questions correctly. (Table 1)

Occasionally, one or the other of the patients were not able to attend some sessions due to their medical condition or relapse of their psychiatric condition. Occasionally there would be a family member who could not come for a session, thus another family member was asked to replace him or her. Since most of the family members were from Region IV and of the low socio-economic bracket, a small transportation allowance was given as an assistance. Simple snacks were likewise provided during the break.

Occupational Therapy (OT) Program

The OT program was created by a licensed Occupational Therapist. It was conducted by two licensed occupational therapists and one OT assistant who conducted the activity four 4 times a week for four consecutive months. This was held in the social hall of the hospital because the OT room of the hospital could not accommodate more than 10 patients at a time. A staff nurse was also present during these activities to provide assistance in case patients became agitated.  The 35 patients in the experimental group could not be accommodated in 1 OT session, since there would only be 1 Occupational Therapist and 1 Nurse Assistant to facilitate the OT session; thus they were divided  into 2 groups-  A  & B  – using the fishbowl  technique. Group A consisted of 17 patients while group B had 18 patients. (Table 2)

All activities began with a review of the house rules, introduction of the activity and its aim, followed by the conduct of activity. The session ended with an occupational performance assessment of what transpired in the session. For self-report assessments, the patients were assisted by the research assistant and the nurse. Afterwards, self-report assessments were collected. For COPM, the occupational therapists conducted an evaluation of each patient’s performance after the session.  (Table 2)

In the 1st month of the program, basic food handling and leisure/arts and craft activities where conducted alternatively every other day. The middle phase of the program alternately conducted activities between intermediate food handling with basic cooking and interactive group games/arts and crafts. The 3rd to 4th month of the program alternately conducted the advanced food handling and cooking and competitive sports. All patients in the experimental group were encouraged to attend the sessions regularly. However, some patients were not able to attend the sessions due to medical concerns or relapsed into psychosis n the middle of the study. In the latter part of the study, 1 patient was discharged due to medical conditions that had to be treated at home as per the policy of the Cavite Center for Mental Health (CCMH).

Statistical Analysis

Statistical analysis was conducted using MS Excel and PH Stat. SPSS v.20.0 was used to check the validity of the data. Frequencies and percentages were calculated for the socio-demographic profiles. Means and standard deviations were computed for the pretest middle and posttest scores of the mental health measures used in the study. For measuring the clinical significance of PSR effectiveness, the paired sample t-tests were used comparing pretest and posttest scores. The significant differences in the four assessment tools between experimental and control group was measured by the t-test for independent samples. Initial scores of the test given during the start of the program were compared against a repeat score based on assessments after the psycho-social rehabilitation program was completed. Pearson R correlation coefficient was used for the computation of the relationship of variables, to check if any of the dependent variables were correlated with the independent variables of the study. Level of significance used in this research was two-tailed and the probability level of significance is 0.05. Quantitative data were presented in tables with corresponding narrative discussion of results. For the overall computation of the data, measures with missing data were excluded from analysis, similar to how demographic data, pre-test and post test scores were treated.

At the end of the PSR program, the clinical significance and social validity of the study was determined by a qualitative study based on patient’s recorded semi-structured interviews. The phenomenological approach was used as a qualitative method of analysis to give a detailed presentation of their perspectives about the psychosocial rehabilitation and their recovery process.

The audio recorded interview data and field notes were transcribed by an independent transcriptionist. Then, the researchers read the transcript repeatedly and each line of the transcript was analyzed. Transcripts underwent 2 coding processes by the senior researcher while on audit trail and review of transcripts by a psychiatrist. Themes of responses were derived from the transcripts, sorting it according to similarity in categories. The findings were presented to the expert consultant for qualitative research who did the audit trail of the codings to enhance the critical analysis of the findings. Triangulation was used to ensure proper data analysis. The IPA model following 5 steps in terms of doing the analysis of the data was utilized. (23)

Analysis of the responses of the study participants was done using two phases, mainly Giorgi’s phenomenological text analysis (23) and hermeneutic interpretation using relevant theories. (22) The focus of the text analysis was geared towards participant’s perspective of recovery and those that contributed as a facilitator and/or barrier of their mental health recovery process. Using the phenomenological approach, the responses of the patients were analyzed to understand their perspectives on the recovery process, treatment gaps and problems under the psychosocial rehabilitation program.

Ethical Considerations

Permission to conduct this study was sought and obtained from the Institutional Review Board of St. Cabrini Medical Center- Asian Eye Institute Ethics Review Board. This research was given ethical clearance by the agency’s Institutional Ethics Review Committee (IERC) required for researches involving the use of human subjects.  The study was conducted in compliance with the Declaration of Helsinki on research and the principles of good scientific practice. This research has ensured that the investigators protected the life, health, dignity, right to self-determination, privacy and confidentiality as well as safeguard the integrity of the participants throughout its implementation. Ethical considerations were also based on the National Ethical Guidelines for Health Research of 2017 under the section “Ethical Guidelines for Health Research” and “Ethical Guidelines for Epidemiologic Research. All participants were asked to sign an informed consent form if they were willing to participate in the research. (24)

RESULTS

The study initially recruited 70 participants, these participants were randomly assigned to the experimental (n=35) and control group (n=35). However, after attrition, the study had 65 participants only, 32 for experimental group and 33 for control group. For the attrition, there were 3 participants dropped from the experimental group, 2 participants dropped out due to medical conditions, and 1 was diagnosed as having a bipolar disorder rather than schizophrenia. For the control group, 2 participants were dropped due to a medical condition; and another respondent was dropped 3 weeks after pre-assessment while another one was dropped more than a month after the study had commenced. 

The demographic profile of participants revealed that most of the 65 respondents were male (n=41, 63.08%), single (n=58, 89.23%) and in their early to middle adulthood (n=42, 64.62%) with ages ranging from 20-40 years old.  They had all been to school, with the majority having reached high school or actually graduated from high school ( n =38, 58.46%). The length of confinement in the hospital showed that most of them had been confined from 1-10 years (n=54, 83.08%) and 38 (58.46%) had a history of at least 1-4 admissions. (Table 3)

Experimental Study Results

The mean scores of the experimental group who underwent 3x/week occupational therapy sessions were measured from the OTTOS. The activities were grouped according to their respective categories. Mean scores falling within the 6-10 range values were considered to be FUNCTIONAL, while scores falling in the range of 1-5 were deemed as DYSFUNCTIONAL according to the standard set by OTTOS. There were no pre-test and post-test scores for the OTTOS since the activities were varied and changed based on the design of the program. (Table 4)

Results of the task observation scale(domains of engagement, coordination, follows direction, quality of work, independence, initiative, decision making, concentration, frustration  tolerance and problem solving) showed that their scores on the basic food handling activities were within slightly functional level, while the Advance Food Handling activities were on the highly functional level.

Results of the general behavior scale (domains of Appearance, Activity level, Expression, Cooperation and Socialization) showed that the lowest scores were under the Leisure Activities ranging within the slightly functional level while the highest scores belonged to the Advanced Food Handling Activities considered as Highly Functional in category. In comparison to all activities, Leisure activities appeared to have the lowest scores in both the task behavior and general behavior assessment.

The “Pagsusuri ng Occupational Therapy Session” (PSOT) was used to measure the experimental group patients subjective view of Occupational Therapy (OT) activities. Under this assessment, patients who have undergone occupational therapy sessions were given opportunities to measure their subjective satisfaction in each activity or session There were no pre-test and post-test analysis of scores in this assessment since OT activities were varied and changing depending on the design of the program. (Table 5)

Leisure activities had clear and understandable instruction, with the highest mean scores while the Interactive games had the least means scores. The most fitted OT activity for the experimental group patients were the Competitive Sports, which had high mean scores while the lowest mean score was obtained  from the Interactive games. For the subjective view of patients in terms of appropriate length of OT activity, patients favored Leisure activities while the Intermediate Food Handling activities seemed to get the lowest mean scores. With regards to the subjective view of which OT activity was useful for them, the Basic food handling activities got the highest mean score, while the Arts/Crafts activities got the least mean score. Lastly, the OT activity that patients looked forward to attending again was the basic food handing activity which got the highest mean score.

Table 6 presents the scores of the pre and post-test of the experimental group based on the overall psychoeducation program and the 6 topics of psychoeducation program.

There was a significant difference in the pretest and post test scores among the experimental group on Psychoeducation Program  sessions 1 (.001***, P = > 0.05) and 2 (.028*, P = > 0.05) using dependent t-test/). The first session discussed the importance of PSR and session 2 discussed the signs/symptoms and  medication for schizophrenia. There was no significant difference in the pretest and post test scores of the Overall Psychoeducation Program Assessment and Psychoeducation program topical sessions 3, 4, 5 and 6 (Role of Family, Communication and Stress Management, Hygiene, Exercise, Nutrition and Sleep, and OT: Livelihood) among experimental group participants using dependent t test.  (Table 7)

Pre-test scores in illness severity factor revealed that both the experimental and control group fell under the level of borderline mentally ill. (Table 8)

Post-test scores of Experimental group in global improvement fell at the level of Borderline Mentally Ill, while control group scores increased to the Mildly Ill category. Significant differences in the severity illness subscale pre and post-test scores of the control group (p=0.029, α =. 05) using dependent t-test were noted. (Table 9)

 The pre-test and post-test global improvement scores of the experimental group and control group fell within the much-improved level. Significant difference in the severity illness post test scores of the experimental and control group (p =0.0327, α =. 05) using dependent t-test were also noted (Table 9). The clinical global improvement pre-test scores of experimental and control groups (p = 0.0354, α =. 05) using dependent t-test have significant differences. The side effect post test scores of the experimental and control group (p=.0306, α =. 05) using dependent t-test also had significant differences. There were questionnaires that were invalidated; only those who completed the questionnaires were included in the computation thus only 29 were formed the experimental group and 27 formed the control group. One of the patients CGI scale had missing items rendering it invalid and had to be excluded from the analysis.

Table 10 illustrates the overall BPRS scores of experimental and control group patients. One of the post tests of the patient had in the control group was invalid thus excluded in the analysis. One of the patients BPRS assessment had missing items rendering it invalid and had to be excluded from the analysis.

The brief psychiatric symptoms of patients, showed that there was a significant difference in the psychiatric symptom pre and post-test scores of the experimental group (p = 0.007, effect size= -0.332) using dependent t-test. (Table 11)

Significant difference in the psychiatric symptom post test scores of the experimental and control group (p = 0.026, α =. 05) using dependent t-test were also noted. (Table 12)

Occupational performance scores on the pretest level of experimental group fell at the low level and control group patients fell on the moderate level. Evaluation of posttest occupational performance scores revealed that the Experimental group participants fell within the “able to perform at a moderate level”.  Conversely, the control group fell within the “able to perform at a low level” category. There was also a significant difference in the Performance scores on the pre-test and post-test activity of the experimental and control group (p = 0.000 α =. 05) using t-test dependent statistic. Occupational performance satisfaction scores on the pretest level of experimental group and control group patients fell both below the satisfied level. The post-test scores of experimental group regarding satisfaction in occupational performance fell within highly satisfied category while the scores of control group participants fell in the moderately satisfied category. (Table 13)

Significant difference testing in the occupational performance satisfaction area pretest and posttest scores showed that experimental group appeared to be significant (p = 0.000, α =. 05) while in the control group was not significant (p = 0.616, α =. 05) based on the dependent t-test. (Table 14)

 Comparing the Pre-test results test of significance in the performance (p = 0.0947, α =. 05) and satisfaction (p = 0.878, α =. 05) area of the experimental and control groups did not appear to be significant. (Table 14)

On the other hand, post test results showed significant differences between the experimental and control groups in the performance (p = .000, α =. 05) and satisfaction (p-value= .000) using dependent t-test. Impact of interventions of occupational therapy sessions in both the performance (effect size = 0.795) and satisfaction (effect size = 0.747) post-test scores of the experimental group produced a moderate effect size. However, the control group showed  negligible effect sizes in both the performance (effect size = -0.174) and satisfaction (effect size = 0.124) area. Only completed questionnaires were included in the computation thus changing the number for the experimental group. (Table 14)

Majority of the participants in the experimental group and control group moderately rated their overall life satisfaction and contentment as adequate in terms of living situation, ability to engage in house hobbies, medication and treatment received.

Comparison of experimental and control group results in terms of quality-of-life enjoyment and satisfaction scores did not show significant differences. The very slight decrease in scores did not appear to be significant in both groups. Thus, investigators surmised that there was not much change in their attitude towards quality of life or that they did not experience change in their quality of life because they were still admitted in CCMH. (Table 15)

Correlation analysis showed that the clinical status of the control and experimental group patients was not correlated with any outcome measures used in the study (Table 16 & 17).

Qualitative Study Results

This study underwent qualitative analysis to further evaluate the outcome of the PSR Program and identify gaps and concerns in its implementation based on patient’s views. There were seven major themes identified. (Appendix 1 &2)

View of Recovery Process under the PSR Program

Patients who had undergone PSR Program viewed recovery as compliance to treatment and attaining self-improvement. Compliance to treatment meant regular intake of medication and following treatment advice.

Perspectives on PEP

Patients who had undergone the Psychoeducation Program reported general changes in self-such as having a positive perspective toward their illness, improved social occupational functioning and feelings of happiness.

Moreover, qualitative interviews revealed that improved social relations extended to periods outside of the Psychosocial Rehabilitation Program. Most of the patients observed less conflict among co-wards and they would often communicate with others during ordinary center activities that were not previously observed by these patients. The researchers surmised that frequent engagement increased their awareness of others and heightened their sensitivity of others in a relational way.

One patient reported remission of auditory hallucinations. While this may not be totally attributed to the PSR program because of several factors such as effects of their medication and the continuing psychiatric care they received, nonetheless the PSR program may have facilitated the remission of symptoms.

Changes in Relationship with Others & Lessons Learned in the PEP

Other patients subjected to the PEP program were also observed to have changes in their relationship with family and other individuals. These patients recognized receiving help, care from center staff and the researchers, who helped them understand their situation and remove the social stigma. They also noticed that with improved relations, their ability to communicate improved and some were even persuaded to stop smoking.

Patients learned valuable lessons such as the role of family, self-care, knowledge about their illness, and relating with others. They learned the importance of family member’s role in their recovery. Patients also learned to relate better and connect with others as they began to understand their illness and symptoms.

Lessons Learned in OT Sessions

Patients who had undergone OT realized that engaging in activities like cooking and playing leisure games were productive. Patients learned that socializing with others, feeling good about themselves, especially in following the rules and guidelines of the program were also important.

Useful Activities in OT Applied when Discharged

Cooking was a practical skill they could use to earn a living once discharged from the hospital. Likewise, rehabilitation process also involved the opportunity to engage in activities which could lead to developing socio-occupational skills.

OT Sessions Impact on Motivation to Work

The OTP helped in instigating patient’s motivation to work.  This positive attitude was inspiring considering that before the program, the patients had no desire to work- thinking they were not fully recovered or that they could not take care of themselves.  However, it should be noted that one patient still had no desire to work after undergoing the OTP as he felt that he was still not fully recovered and unable to care for himself.

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DISCUSSION

The findings of the study examined the impact of PSR, combining both psychoeducation and occupational therapy sessions were similar to other study findings that patients receiving it were more likely to be unmarried, chronically ill and have been frequently hospitalized. (25)

Overall findings revealed that the PSR helped reduce the psychiatric symptoms of the patients. This study yielded the same results with an eight month follow up study of rehabilitation among patients in Turkey, which showed that there was a significant decrease in scale scores of psychiatric symptoms for schizophrenic patients following rehabilitation training. (26)

This finding was also similar to a comparative study supporting the idea that PSR was effective among mentally ill patients. (10) However, it is noteworthy to mention that, there was no significant improvement in terms of illness severity, but the illness of those who received the PSR interventions did not significantly deteriorate as compared to the control group who did not receive the intervention.

Observation of performance and satisfaction mean scores of the first, second and third to four months of the given activities showed that scores were higher on the second and third months, respectively showing better functional performance and progress through the short period of time. Progression of the mean scores to the higher end of the scale could be seen on the third and fourth months. This finding suggested that the progressive functional performance of the patients as months passed could also be attributed to their increasing involvement and enjoyment in the activities and their perceived usefulness of the tasks that they were engaged in.

The occupational therapy program had an increasing positive effect in the task behavior and general behavior as well as their overall functioning during the months of intervention. Evidence showed that the PSR was effective in increasing socio-occupational function particularly their performance level and degree of satisfaction on previously identified activities for which they were not confident to perform.

This result was consistent with the findings of Margolis et al in 1996 wherein patients who had undergone psychosocial rehabilitation program using OT had increased in functional capacity and patient function during task groups. (20) Other studies pointed out that attending occupational therapy sessions caused an improvement in social functioning of patients with schizophrenia. (27)

Likewise, rehabilitation using occupational therapy also involved the opportunity to engage in activities, which led to the development of one’s socio-occupational skills. The individual then began to see his own development through learning skills. (28) In addition, based on their self-report assessment of occupational therapy activities, patients were more inclined to choose leisure activities as they found the instructions more comprehensible and activities enjoyable. This coincided with the study of Wallace in 1998 that giving of focused instruction on OT activities was useful because it helped in the achievement of better performance. (29)

On the other hand, patients who did not undergo OT sessions had experienced a decrease in socio-occupation functioning. Patients who underwent the PSR program benefitted from improving their cooking skills, playing games, socializing and remaining physically and mentally healthy. Findings in other studies point out that attending occupational therapy sessions resulted in an improvement of social functioning among patients with schizophrenia.(27)

Qualitative interviews in terms of occupational therapy performance revealed that the experimental group patients found more hope, meaning and purpose in the occupations or everyday tasks and activities that they did. Having a personally meaningful occupation and feeling that one has contributed was an important determinant of health and well-being. (30) Thus, patients did experience recovery in terms of occupational functioning by finding satisfaction and having a sense of contribution in life despite experiencing limitations brought about by the illness. (30) This finding was similar to other studies that showed schizophrenic patients who underwent an occupational therapy program had experienced clinical and quantitative changes in their performance and satisfaction level. (30)

Psychoeducation topics like discussing and understanding their illness and strategies that dealt with symptoms were effective in the reduction of signs and symptoms of schizophrenia. One patient reported remission of auditory hallucinations. While this may not be totally attributed to the PSR program because of several factors such as effects of their medication and the continuing psychiatric care they received, nonetheless the PSR program may have facilitated the remission of symptoms. The finding of this study was similar to Valmaggia et al in 2005 wherein patients with psychotic symptoms showed a significant decrease in auditory hallucinations. (31)

In addition, according to the study of McGorry in 2005 (32), psychoeducation was capable of reducing stigma and enhancing self-esteem, factors that influenced recovery experience in schizophrenia. This was also mentioned in the study of Walker et al in 2012 who mentioned that psychoeducation was an intervention that seemed to improve patients’ knowledge regarding their disorder, which accounted for the improvement of their insight and mental status. (33)  

Psychoeducation also provided patients information that led to increased ability to manage associated symptoms and cope with cognitive and social deficits along with decreased rates of relapse, improvement in medication compliance and increased individual’s treatment satisfaction. (34)

Qualitative interviews corroborated that patients had gained a more positive outlook towards their illness. Some of the patients had begun to hope and see the possibility that their symptoms could be controlled and felt their condition had improved as opposed to previously feeling discouraged and disempowered due to the chronic nature of their illness. This finding was also evidenced in the study of Petersen et al in 2015, which meant that individuals gained faith in the possibility of recovery. (28)

Psychoeducation also helped most of the patients realize the importance of medication. Some of the patients learned that regularly adhering to medication could help manage their symptoms or prevent relapse. Studies showed that psychoeducation helped patients gain deeper understanding and insight into their illness. (35)

Iseselo et al in 2016 pointed out that medication was considered to be an important part of recovery by mental health patients. (36)  However, patients’ struggle in taking medications was prevalent and for this reason, constant psychoeducation would be needed. In addition, patients realized that they needed to follow treatment advice of the mental health professionals as shown in qualitative interviews. Literature showed that healthcare professionals played an important role in facilitating recovery by educating them and providing supportive therapy for their patients. (37)

Self-improvement was an individual effort that required active participation in identifying areas of weakness and taking necessary steps to improve them, which could be facilitated by healthcare professionals.  The same study showed that recovery was viewed as an individual process depending on individual efforts and hard work. Rehabilitation allowed the individual to make changes and to work actively towards recovery.  (28)

Although the interventions did not generate good statistical results on quality of life, we surmised that the patients’ view on their quality of life did not change since they were still living within the same hospital. A longer implementation of the interventions or a longitudinal cohort study would be necessary to measure the improvement in the quality of life of patients.

Findings in this study suggested that the treatment and recovery process of schizophrenic patients was influenced by other approaches in psychosocial rehabilitation and not just limited to the confines of pharmacological treatment. Topics like the role of psychosocial rehabilitation and knowledge about the disorder also brought better understanding of the illness, the symptoms, required medications and strategies in handling their symptoms based on the results of the study. This resulted in improved subjective well-being of the patients and better relationship of the patients with their families. The combined interventions undertaken by both patients created some positive impact in the subjective well-being of the patients and their social skills. Knowledge in properly caring for the patient and provision of practical family support seemed to be enhanced among family-caregivers. St. Jacques in 2004 mentioned that any practical help given by the families did create a good impact for the mentally ill patient. (38)

Other various learnings were obtained by the patient both from undergoing the psychoeducation and occupational therapy program including learning practical and enjoyable activities and skills, increased motivation to work, having general positive changes in self, relationship with family and co-wards. Similar to the findings of this study, showed that psychoeducation increased individuals’ insight into illness and affected sociability. (33)  In addition, the study of Chądzyńska & Charzyńska in 2011 also showed that those who had undergone psychosocial rehabilitation did experience improvement in mood. (39)

Limitations

Although the psychosocial rehabilitation program showed some positive effects on patients with schizophrenia and their caregivers, the brief amount of time allotted for the intervention process was a limitation. The 6-month study, despite some positive outcomes, was not long enough to determine its sustainability over time. Longitudinal studies of recovery process maybe more effective in supporting positive changes gained in the rehabilitation process. Short term interventions may work to a certain extent but long-term efficacy may be difficult to measure considering many factors and life events that would have to be controlled or taken into account. The researchers did not control for other confounding variables such as other clinical status of patients and only relied on the inclusion criteria and enrolled patients and families who were willing to join the program.

The study adapted the PMHA model of psychoeducation program since this has been consistently conducted and the researchers needed a strong model to follow. Although there were changes based on a general framework of the psychoeducation program, the adaptation of the PSR model as a study limitation was considered. The design of the program would have been more suited to the participants if there were interviews conducted with the practitioners, patients or family members regarding their needs and views prior to the implementation of the program. It is also noteworthy to point out that despite patients having developed new skills during PSR, opportunities for practicing these skills were limited inside the mental health facility. Integration of new knowledge and skills learned in psychoeducation and occupational therapy to daily living may require more time to learn.

Drop-out rates due to physical and mental illness of some patients affected the outcome of the study. Schizophrenic patients experienced relapse of symptoms during the study period. Their absence in the sessions due to relapse and other medical related concerns affected the results of the study i.e. resulting in varying sample size.  Since patients were living in the same mental health facility despite having their own separate quarters, we did not have control over the possibility of their interacting with each other due to hospital wide events thus allowing for the possibility of sharing stories and influencing each other in their responses.  

Some family members did not attend any of the psycho-education program sessions, which may have affected the emotional subjective well-being of their patients compared to those patients whose family members did attend most of the time. Although family members’ attendance was considered important to the psycho-education process, difficulties in convincing them to attend were encountered. The extent to which, it affected the reaction of the participants to the program was not measured and this was not taken into account as a confounding variable in the statistical analysis of the effectiveness of the program.

Lastly, although significant and psychologically meaningful categories of patients’ recovery process were gathered, the researchers noted that qualitative results of the study were not generalizable and were only applicable to the respondents of this study.

Another limitation of this study was that the newly created tools like the PSOT, PSP & IGQ were only validated by their content but not yet pretested on a similar group of respondents.  Because of this, one of the recommendations is that these tools be pretested and measured in terms of reliability to a similar group of patients to determine their true validity.

Recommendations

In order to implement the Psychosocial Rehabilitation Program (PSR), the researchers emphasize that both the Occupational Therapy and Psychoeducation Program be applied in combination with pharmacologic treatment to facilitate recovery of schizophrenic patients in mental health facilities. It is also recommended that the OT Program should be conducted more frequently i.e. 3-4 days/week for a prolonged time period e.g. 2-4 hrs for greater integration and better socio-occupational progress so as to facilitate mental health and recovery among these patients.

Individual assessments of the occupational needs, interests, difficulties and challenges should be done for each patient prior to the start of the PSR intervention while the programs should also be based on the needs and interests of the patients. The needs and interests can then be grouped or categorized in order to design the appropriate Occupational Therapy Program.

Considering the various activities involved in the occupational therapy program, it is highly recommended that mental health facilities should allocate adequate space and material resources to implement this program more effectively. Professional and competent occupational therapists should be hired to run the OT program. The OT staff should be trained and guided by the occupational therapist during the activities with a ratio of 1OT:15 patients.  

For community integration, local partners should be identified and encouraged to conduct the program in the local health center or rural health units. They should be trained for simple occupational therapy sessions to allow for follow-up and monitoring. This will reduce the probable relapse of patients or prevent the severity of their symptoms. Positive impact of occupational therapy sessions could also increase if family members were involved in the program. These family members may be given awareness training, occupational therapy education and be involved in helping the patient for discharge, and for planning suitable activities that can be done at home. This can also strengthen the social support given to patients, which is vital for their well-being and sense of self worth.

For the Psychoeducation program, a minimum of 1 1/2 hours with a participative approach is recommended with the sessions on knowledge of PSR, signs and symptoms of schizophrenia and the importance of medication should be retained. The facilitators could be multidisciplinary that includes: psychiatrist, psychologist and recovered patients with their family members to provide a wider perspective and variety of strategies so that the patients are motivated and not bored. As for the other topics of the psychoeducation program that have not shown evidence of change in pre & post treatment during its running, we recommend a redesign in terms of the topic and implementation.

Lastly, a separate mental health facility is recommended for conducting of PSR study to control unavoidable contacts of patients in both the experimental and control group to minimize any collusion effect. We also recommend a longitudinal study of at least 1-2 years to measure the impact of both the occupational therapy and psychoeducation program. This would have examined the sustained impact of the interventions on the patients. It would also be helpful if we could also examine the impact of PSR program on the families who joined the psychoeducation program over a longer period of time.

ACKNOWLEDGEMENTS

Department of Science and Technology, Department of Health and the Philippine Council for Health Research & Development for approving the grant of this research.

Financial Disclosures: The authors have declared that no competing interests exists.

Partner Institutions: Institute of Family Life, Women and Children Studies- Philippine Women’s University and Cavite Center for Mental Health

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