Psychosocial skills training on social functioning and quality of life in the treatment of schizophrenia: a controlled study in Turkey

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1 Y:/Taylor & Francis/mpcp/articles/Mpcp7803/MPCP7803.3d[x] Wednesday, 8th September :1:0 # 2004 Taylor & Francis International Journal of Psychiatry in Clinical Practice 2004 Volume 8 Pages 1 /7 1 Psychosocial skills training on social functioning and quality of life in the treatment of schizophrenia: a controlled study in Turkey MUSTAFA YILDIZ 1, BAYBARS VEZNEDAROGLU 2, AYSE ERYAVUZ 2 AND BULENT KAYAHAN 2 1 Department of Psychiatry, Kocaeli University School of Medicine, Kocaeli, Turkey, and 2 Department of Psychiatry, Ege University School of Medicine, Izmir, Turkey Correspondence Address Mustafa Yildiz, MD, Associate Professor of Psychiatry, Department of Psychiatry, Kocaeli University School of Medicine, Derince, 41900, Kocaeli, Turkey Tel: /(90) Fax: /(90) myildiz60@superonline.com OBJECTIVE: This study assessed the impact of a psychosocial skills training program, consisting of psychoeducation, interpersonal group therapy and family education incorporated into social skills training, as an integrative approach on social functioning and quality of life of patients with schizophrenia, in comparison to standard care for an 8-month period. METHOD: Thirty patients with DSM-IV schizophrenia were included in the study. Patients were assessed using the Positive and Negative Syndrome Scale (PANSS), Quality of Life Scale (QLS), Social Functioning Scale (SFS), and Global Assessment of Function (GAF) at baseline. Fifteen patients underwent an 8-month psychosocial skills training group program and another fifteen patients (waiting list) continued in standard care. Both groups were reassessed and analyzed at the end of the study. RESULTS: Two groups were not statistically different in terms of total PANSS, QLS, SFS, GAF scores, and demographic characteristics at baseline. However, there was a significant improvement in the mean total QLS, SFS, GAF, and even in total PANSS scores (respectively from /19.58 to /24.10, PB/0.001, from /22.85 to /33.85, P B/0.002, from /8.78 to /7.57, P B/0.012, and from /14.48 to /15.71, P B/0.029) for those who underwent the PSST program, but there was no statistically significant change for those on standard care at the end of the study. CONCLUSION: This study highlights the social functioning and quality of life benefits of the psychosocial skills training program for patients with schizophrenia. It can be concluded that this comprehensive psychosocial skills training program might be an important contribution to the functioning of the patients. (Int J Psych Clin Pract 2004; 8: 1/7) Keywords schizophrenia psychoeducation group therapy quality of life psychosocial rehabilitation social skills training social functioning INTRODUCTION S chizophrenia impairs the development of psychosocial skills needed for useful, independent living, social functioning, occupational skills, and self-care. 1 Impairment of social functioning in schizophrenia is widespread and may reflect a primary impairment as well as a secondary disability. 2 Although antipsychotic drugs reduce psychosis, protect against stressors and, taken life-long, prevent considerable relapse and re-hospitalization, 3 5 the overall level of functional outcome of patients with schizophrenia has not been improved markedly. 6 On the other hand, drug side effects and compliance in patients with schizophrenia is still a continuing problem in their treatment. 7,8 The majority of patients with schizophrenia, even those who benefit from medication, continue to have disabling residual symptoms and impaired social functioning and will most likely experience a relapse despite medication adherence. Hence, DOI: /

2 Y:/Taylor & Francis/mpcp/articles/Mpcp7803/MPCP7803.3d[x] Wednesday, 8th September :1:0 2 M. Yildiz et al it is necessary to integrate psychosocial treatments into the standard of care for this population. 9,10 Psychosocial interventions for patients with schizophrenia aim at enhancing interpersonal and social role functioning, promoting independent living and community tenure, decreasing symptom severity and associated comorbidities (e.g. substance abuse), and improving illness management. 11 As a holistic approach to the treatment of schizophrenia, pharmacotherapy and psychosocial interventions work together to reinforce one another s efforts and improve the efficacy of coordinated care. There are nine major approaches that are particularly promising in psychosocial interventions in schizophrenia, when provided in conjunction with neuroleptic medication: (i) social skills training, (ii) psycho-education, (iii) cognitive rehabilitation, (iv) cognitive-behavioral therapy, (v) family therapy, (vi) personal therapy, (vii) group therapy, (viii) case management (assertive community treatment program), and (ix) vocational rehabilitation. 10,11,15,16 From these approaches, social skills training, especially when it is combined with psychoeducation, illness management techniques (medication management and symptom management skills), and family education, and continued for a long period, was reported to be more effective than standard care, supportive group therapy, and occupational therapy in respect to social adjustment and the generalization of skills, but not markedly more effective on symptom outcome and relapse rate. 20,21 Social skills training aims at improving the individual s coping skills, promoting problem solving, engaging in affiliative and instrumental relationships, mobilizing a supportive network, and adherence to medication. 22 Psychoeducation programs for patients with schizophrenia target improving understanding and insight into psychotic illness itself and skills of self-management and medication management. 23 Family education aims to provide information concerning the nature and course of schizophrenia, as well as specific management strategies thought to be helpful in coping with schizophrenic symptoms for family members. 24 The current status of psychosocial treatment of patients with schizophrenia is nevertheless still unsatisfactory in Turkey. Although there have been some endeavors since the 1970s, 25 there is now no institutionalized or established rehabilitation program for these patients even in the big Mental Health Hospitals. As a relatively new effort, the Medication Management 26 and Symptom Management 27 modules of the Social and Independent Living Skills were studied in a sample of Turkish patients with schizophrenia (with no control group), and it was concluded that these are easily applicable and effective rehabilitative interventions 28 for Turkish patients. There is a lamentable paucity of research on the psychosocial treatment of schizophrenia and a lack of well-controlled studies to evaluate the efficacy of such interventions in Turkey. The impact of such programs on social functioning, quality of life, psychopathology, and on the course of the disorder still remains uninvestigated. Another serious problem is the lack of skilled trainers or therapist for patients and their families. Therefore, we need a new treatment approach that should be comprehensive, effective, and practical and that could be easily learned, put into practice, and disseminated throughout the country, which has few resources for the rehabilitation of schizophrenia. The psychosocial skills training (PSST) program used in this study was prepared using the techniques explored in the basic references The program consisted of three components of Social Skills Training (the basic model, the social problem-solving model, and the cognitive remediation model), 32,33 psychoeducation 19 in the interpersonal group therapy 34 format, and family education. 35 Its emphasis is especially on the developing or improving of social skills, problem-solving strategies, interpersonal relations, adaptive interactions, insight into their illness and related problems, coping strategies for the warning signs or persistent symptoms, and strengthening of ego functions of the patients by engagement of the family as an ally in the treatment process as an integrative approach. The aim of this study was to investigate the role of the comprehensive model of psychosocial skills training on social functioning and quality of life of patients with schizophrenia. The main hypothesis was that patients taking PSST would be more likely to have increased social functioning and increased quality of life when compared to those taking standard care over the 8-month period. METHODS SUBJECTS Clinically stable (no psychiatric hospitalizations or changes in psychiatric medications for 3 months prior to the study entry) patients with schizophrenia according to DSM-IV 36 from two different sites, University of Kocaeli and University of Ege Hospital outpatient clinics, were included in the study. Subjects were excluded if they had any of the following: (i) evidence of an organic central nervous system disorder; (ii) current alcohol or drug abuse or dependence; (iii) mental retardation; (iv) were aged under 18 or over 65 years; (v) had a high level of positive symptoms which could interfere with the participation of a group; or (vi) had participated in any group therapy or educational program beforehand. This study was described verbally to each subject prior to obtaining informed consent. STUDY DESIGN Patients were assigned to two groups according to the sequence of their admission in each center. The first 15 patients regardless of their demographic, clinical or functional status were enrolled in a training group (Group I) and the subsequent 15 patients (waiting list) were enrolled in a standard care group (Group II). Family members who were important for the patients were allowed to participate in the

3 Y:/Taylor & Francis/mpcp/articles/Mpcp7803/MPCP7803.3d[x] Wednesday, 8th September :1:1 Psychosocial skills training 3 family education. That is, Group I patients were assigned to psychosocial skills training including family education plus standard care, and Group II patients were assigned to standard care alone for 8 months. the education program, PSST program patients received standard care monthly. PSYCHOMETRIC ASSESSMENTS STANDARD CARE The patients assigned to standard care received the usual treatment provided to University Hospital clients. It includes pharmaco-therapeutic approaches and discussion for treatment issues with the patients and families. All patients visited the psychiatrists once a month for their treatment during the study. PSST PROGRAM The psychosocial skills training program is a structured educational training program that has a manual for trainers like the UCLA Social and Independent Living Skills training modules. 37 This manual is a curriculum which includes specific skills areas (e.g. communication skills, coping skills for persistent symptoms) with a variety of structured activities that include role playing, problem solving, and other exercises (Table 1). The PSST program was administered for 8 months by one or two trainers, who were clinically experienced psychologists and nurses, to the patients (weekly for 90 minutes in two sessions) and to the families (biweekly for 90 minutes in one session) in a group room. Trainers were trained to administer the PSST in a competent manner for 1 week before the study, and supervised regularly every month during the study. Besides Patients were assessed using the Positive and Negative Syndrome Scale 38 (PANSS), Global Assessment of Functioning 36 (GAF), Social Functioning Scale 39 (SFS), and Quality of Life Scale 40 (QLS) in terms of symptom status, social functioning, and life quality at initial/baseline assessment and at the end of the study. PANSS was used to obtain ratings for positive, negative, and general symptoms. Two experienced psychiatrists, who were blind to the study, administered the Turkish version of PANSS. 41 GAF is a 100-point rating scale that assesses psychological, social and occupational functioning. Two experienced psychiatrists, who were blind to the study, administered the GAF. SFS is a 79-item scale designed to assess social functioning in seven areas (social, interpersonal communication, activities of daily living, recreation, social activities, competence at independent living, and occupation/employment) in schizophrenia. Family members completed the Turkish translation of this form. QLS is a semi-structured interviewer-administered scale containing 21 items. It measures adjustment on four subscales: interpersonal relations, instrumental role functioning, intra-psychic foundations, and common objects and activities. The Turkish version of the QLS 42 was administered by two experienced psychologist who were blind to the study. Table 1 Contents of and techniques used in the PSST program Skills areas in the PSST program Learning and therapeutic techniques used in each skill area 1. Improving cognitive skills, 1. Giving information about the skill area, 2. Improving communication skills, 2. Sharing experiences, 3. Improving problem solving skills, 3. Correcting wrong attitudes, 4. Understanding psychosis and schizophrenia, 4. Modeling, 5. Learning antipsychotic drug therapy, and drug side effects, 5. Coaching, 6. Evaluating the treatment, 6. Shaping, 7. Learning to cope with persistent symptoms, 7. Role playing, 8. Recognizing warning signs and monitoring them, 8. Cognitive rehearsal, 9. Avoiding alcohol and street drugs, 9. Problem solving, 10. Avoiding unnecessary treatment seeking, 10. Here-and-now interpretation, 11. Learning to cope with stress, 11. Self-control, 12. Enhancement of self-esteem, 12. Self-expression, 13. Leisure time and daily living activities, 13. Self-monitoring, 14. Developing friendship, and 14. Coping techniques, 15. Participating in social activities. 15. Exercises, 16. Homework assignment, and 17. Family education.

4 Y:/Taylor & Francis/mpcp/articles/Mpcp7803/MPCP7803.3d[x] Wednesday, 8th September :1:1 4 M. Yildiz et al The ratings of psychopathology and psychosocial function were made on two occasions. At the baseline and endpoint assessment all assessments were conducted within a 1-month period. The GAF and PANSS were administered in one session, and the SFS and QLS in another session. These sessions would occur on the same day. The same interviewers or family members conducted the same assessments. Case records were used at the baseline and at the end of study to obtain information about medication status before and after the intervention. STATISTICS SPSS for Windows (version 10) was used to analyze the data. Non-parametric tests were used for comparisons. Differences between the groups were assessed using the Mann /Whitney U-test. Wilcoxon Signed Ranks test were used to compare the initial and end point scores of the PANSS, GAF, SFS, and QLS for each group. RESULTS All patients (15 for PSST, 15 for standard care) completed the study for 8 months. There were no statistical differences between two groups with regard to the demographic characteristics (Table 2) and the total QLS (z//1.269, P/0.204), SFS (z//0.976, P/0.329), PANSS (z/ /0.706, P/0.480), and GAF (z//0.929, P/0.353) scores, even in the sub-scale scores of the PANSS, QLS, and SFS at baseline. However, there were prominent differences between two groups at endpoint (Table 3). These differences were also at a statistical level for all sub-scales of the QLS (z//3.964, P/0.001 for interpersonal relations, z//2.103, P/0.035 for instrumental role functioning, z / /3.366, P / for intra-psychic foundations, and z / /3.083, P/ for common objects and activities). With regard to the sub-scales of the SFS, although there were significant differences in interpersonal behavior, prosocial activities, recreation, and independence-performance (respectively, z / /3.117, P/ 0.002, z / /2.806, P/ 0.005, z / /3.127, P/0.002, and z/ /2.102, P/ 0.036), there were no significant differences in social withdrawal, independence-competence, and employment/occupation subscales (respectively, z//1.368, P/0.171, z//1.749, P/0.08, and z//0.917, P/0.359) at the endpoint. There were no significant differences between the groups in regard to the PANSS positive (z//1.033, P/0.302) and general psychopathology (z / /1.246, P/ 0.213) scores at the endpoint. There was a prominent decline in PANSS negative scores in the PSST group (from /5.35 to /6.81, z/ /2.264, P /0.024), but not in the control group (from /6.06 to /6.52, z//1.898, P/0.058), and the difference between two groups was significantly important (z / /2.037, P/ 0.042) at the endpoint. The baseline and endpoint mean total scores of the scales for each group (Groups I and II) are shown in Table 3. Table 2 Demographics and illness characteristics of both groups (Group I, psychosocial skills training group; Group II, standard care group) Characteristic Group I (n/15) Mean 9/ SD Group II (n/15) Mean 9/ SD P value Age (years) / / Education (years) / / Age at onset (years) / / Duration of illness (years) / / Number of hospitalizations 2.339/ / Economic level a / / Mean dosage of medication b Baseline / / Endpoint / / N % N % Gender (Male) Marital status (non-married) Type of disease Paranoid Residual Undifferentiated Disorganized a Average income per person in a family monthly as Turkish Lira (million). b Chlorpromazine equivalent.

5 Y:/Taylor & Francis/mpcp/articles/Mpcp7803/MPCP7803.3d[x] Wednesday, 8th September :1:1 Psychosocial skills training 5 Table 3 Baseline and endpoint scores of the scales for each group (Group I, PSST; Group II, standard care) Scales Baseline Endpoint Z P Group I / /15.71 / PANSS Group II / /19.84 / *P/0.480 *P/0.048 Group I / /33.85 / SFS Group II / /30.24 / *P/0.329 *P/0.005 Group I / /24.10 / QLS Group II / /14.48 / *P/0.204 *P/0.001 Group I / /7.57 / GAF Group II / /7.81 / *P/0.353 *P/0.016 PANSS, Positive and Negative Syndrome Scale; SFS, Social Functioning Scale; QLS, Quality of Life Scale; GAF, Global Assessment of Functioning. *Difference between two groups. There was no difference between the two groups with respect to the treatment change at the end of the study (z//0.372, P/0.710). Mean dosages of medications (chlorpromazine equivalent) used at baseline and end-point are shown in Table 2. There were no hospitalizations in either group during the study period. DISCUSSION We found a higher improvement in all dependent variables for the PSST group, compared to the control group, in all global assessments. Within the quality of life scale, all subscale scores, within social functioning scale interpersonal behavior, prosocial activities, recreation, and independenceperformance and negative PANSS scores, were found to be significantly changed after the training program. It appears that the program has a strongly positive effect on the social functioning, quality of life, and negative symptoms of patients with schizophrenia compared to the standard treatment. Prominent benefits were provided by a combination of psychoeducation, interpersonal group therapy, and family education approaches incorporated into the social skills training. This indicates that psychosocial skills training of patients with schizophrenia can lead more rapidly to improvements in quality of life and certain areas of social functioning which are probably related to negative symptoms. It is known that the functional outcome of patients with schizophrenia is not always the same as the clinical outcome. 43 Social functioning of patients seems to be independent of the severity of psychotic symptoms 44 and influenced by negative and cognitive symptoms. 45,46 In our study, all functioning scales showed a prominent change in the PSST group compared with the standard care group. This could be related to the significant change in negative symptoms or independent of this change. It has been shown that schizophrenia patients with nondeficit negative symptoms are amenable to intensive social skills training. 47 We didn t evaluate the patients negative symptoms with respect to the deficit or non-deficit states. However, the PSST program has been found to have a positive effect on negative symptoms. The improvement in negative symptoms could be considered an interaction between therapeutic factors (i.e. more social interaction, more contact with the treatment team). The PSST, through improvements of self-esteem, motivation, leisure time and daily living activities, interpersonal relations, developing friendship, and participating in social activities, might have had an effect on the enhancement of competence and mastery feelings and hence to a better quality of life which is related to the negative symptoms and social functioning. 48 Long-term educational process together with skills training can provide a contribution to patients and families who recognize themselves as experts in their illness and management of the disorder. Using skills training methods helps participants to actively seek and implement their own solutions to their own problems. Patients are thought to recognize not merely their early symptoms, but also to cope with their persistent symptoms and stresses so that they can find ways of coping more efficiently when they experience excessive stress. The psychosocial skills training program, including the engagement of the family as an ally in the treatment process, could have positively influenced the psychosocial functioning of the patients. Information about skill areas and skills training was provided for families, as had been for the patients at the same time. Detailed information about schizophrenia and its management, such as improving communication, problem solving, medication compliance, crisis intervention, developing social support

6 Y:/Taylor & Francis/mpcp/articles/Mpcp7803/MPCP7803.3d[x] Wednesday, 8th September :1:1 6 M. Yildiz et al networks, and coping skills, might have led the family members to understand the patients and help them overcome their difficulties. In addition, lowering the expectations of the families, developing clear communication and problemsolving skills within the family group, might also have contributed to the reductions in patients negative symptoms and making them more social. Educating the family members about negative symptoms, and setting realistic limits may reduce the family s tendency to criticize the patient, which in turn may encourage the patients social engagement. 24,49 There is growing evidence that psychosocial treatments in schizophrenia must not be considered in the short term, and need to be planned for a long term intevention, and if possible should be continued by booster sessions for a very long period. 15 The PSST program showed beneficial effects on social functioning and quality of life in a period of 8 months. This is a moderate time for a program, hence its effect in the long run need to be evaluated using the same instruments. The study did not address the effects of the PSST program on global clinical outcomes, such as relapse and rehospitalization conditions, in the long term. The significant change of the total PANSS scores in PSST group at the endpoint, though mainly dependent on the change of the negative symptoms, can give some clues that the program might be useful in the prevention of relapse and recurrence of the disease. Some methodological limitations of this study should be considered. The sample size was small. This study needs to be replicated with larger samples. Another limitation is that the standard care program did not include another therapeutic intervention. However, this program has comprehensive approaches that aimed to be incorporated to standard care. Randomization of patients could not be recognized well enough, because the first fifteen patients were selected for the PSST group and the second fifteen patients for the control group. This may not rule out that the members of the first group were more eager to participate in the study than the members of the second group. This could lead to a bias. The level of insight of the patients, which could be a confounding factor for the results, was not measured. Despite these limitations, the present study is one of the first that includes several treatment modalities in one program. This could be a practical tool for practitioners in the psychosocial treatment of schizophrenia. Whether treatment gains continue for a long time should be tested for this program in another study. CONCLUSION It can be concluded that when psychoeducation, interpersonal group therapy, and family education that were incorporated into the SST, were administered as in the PSST program, there is a better outcome than with standard treatment alone. Results clearly support the use of psychosocial skills training in the treatment of schizophrenia, particularly for enhancing social functioning, quality of life, and probably lessening negative symptoms, domains less affected by medication alone. Given its limitations, this study should be understood as an initial exploration of the potential for psychosocial skills training intervention in Turkey, which has few rehabilitation resources for schizophrenia patients. This study introduced promising results. ACKNOWLEDGEMENTS KEY POINTS. Psychosocial skills training program, including family education, might have an important effect on the social functioning, quality of life, and even negative symptoms of patients with schizophrenia. Adjunctive psychosocial treatments augment the benefits of pharmacotherapy and enhance functioning in schizophrenia. The psychosocial skills training program should be regarded as a practical, compromised, and beneficial tool for the treatment of patients with schizophrenia. The authors thank to Selvet Kurdoglu, Gulcin Sungu, and Zehra Caliskan for their invaluable contribution to the study as trainers. AQ1 REFERENCES 1. Lay B, Blanz B, Hartmann M et al (2000) The psychosocial outcome of adolescent-onset schizophrenia: A 12-year followup. Schizophr Bull 26: 801 /6. 2. Bellack AS, Morrison RL, Wixted JT et al (1990) An analysis of social competence in schizophrenia. Br J Psychiatry 156: 809 / Schooler NR, Keith SJ, Severe JB et al (1997) Relapse and rehospitalization during maintenance treatment of schizophrenia: the effects of dose reduction and family treatment. Arch Gen Psychiatry 54: 453 / Robinson D, Woerner MG, Alvir JM et al (1999) Predictors of relapse following response from a first episode of schizophrenia or schizoaffective disorder. Arch Gen Psychiatry 56: 241 /7. 5. Kane JM, Marder SR (1993) Psychopharmacologic treatment of schizophrenia. Schizophr Bull 19: 287 /302.

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8 AUTHOR S QUERY SHEET Author(s): M. Yildiz et al MPCP 7803 Article title: Article no: Dear Author Some questions have arisen during the preparation of your manuscript for typesetting. Please consider each of the following points below and make any corrections required in the proofs. Please do not give answers to the questions on this sheet. All corrections should be made directly in the printed proofs. AQ1 AQ2 See third point in KEY POINTS: compromised does not seem to be an appropriate word here / please amend. Ref. 35: where in CA is the publisher located?