The Effect of A Symptom Self-Management on Psychotic Symptoms for Multiple episodes Schizophrenic Patients

The Effect of A Symptom Self-Management on Psychotic Symptoms for Multiple episodes Schizophrenic Patients Sudaporn Stithyudhakarn 1, Assoc. Prof. Dr.Jintana Yunibhand 2, Assoc. Prof. Dr.Sureeporn Thanasilp 3 1. Ph.D. Candidate, R.N., Faculty of Nursing, Chulalongkorn University, Thailand 2. Ph.D., Faculty of Nursing, Chulalongkorn University, Thailand 3. D.N.S., Faculty of Nursing Chulalongkorn University, Thailand Abstract: Background: Schizophrenia is a severe psychotic disorder and chronic disease. The exacerbation of psychotic symptom has influenced to cause psychotic relapse which the relapse can cause significant personal distress, interfere with rehabilitation efforts, and result in psychiatric hospitalization. Some literatures showed self-management can reduce the severity of symptoms and prevent the complication of disease. As schizophrenia is a critical problem, the Symptom Self-Management Program (SSMP) was developed. Therefore, an evaluation of this program was needed. Objective: To evaluate the effect of the SSMP on psychotic symptoms in schizophrenic patients compared with an usual care. Setting: An outpatient ward at Galya Rajanagarindra Institute, Bangkok. Research design: Randomized control trial. Patients and methods: There were 80 eligible schizophrenic patients. 40 of them were in the control group who obtained usual care while the other 40 were in the experimental group who were obtained usual care in addition to SSMP. The severity of psychotic symptoms was measured by the Brief Psychiatric Rating Scale. Results: The findings revealed that the mean score of psychotic symptoms in experimental group in 1 month after receiving intervention was significant statistically lower than the control group at the level.05. Conclusion: It could be suggested that a SSMP could decrease psychotic symptoms in schizophrenic patients. Therefore, this program can be implemented within nursing practice in order to decrease psychotic symptoms and prevent of complication of disease. Keywords: schizophrenia, psychotic symptoms, symptom self-management Background and Significance of the Study Schizophrenia is a severe psychotic disorder and one of the major mental health problem in Thailand. Patients with multiple episode schizophrenia have experienced with a severe and persistent symptoms that is associated with impairment in daily functioning (Fisher, Geller, Altaffer, 1992). Symptoms of schizophrenia are the concurrent presentation of positive psychotic symptoms (e.g., hallucinations, delusions); negative symptoms (e.g., anhedonia, asociality); and affective symptoms (primarily depressive) (Kitamura & Suga, 1991). Persons with multiple episode schizophrenia are in residual phase which the symptoms occur are mostly the negative symptoms e.g. withdrawal, inactive and ignoring one s self. Psychotic symptoms such as hallucination or delusions may still be presented but not severe 1

in multiple schizophrenic patients (American Psychiatric Association, 1994). The residual phase of schizophrenia have psychotic symptoms similar to the prodromal phase which the symptoms gradually progress and patients need to receive help before the symptom become severe (APA, 1994). The prodromal symptoms or early warning signs are the earliest changes in illness stability and predict of psychotic relapse (Baker, 1998; Bustillo, Buchanan & Carpernter, 1995; Herz & Lamberti, 1995; Lamberti, 2001; Liberman, 1995; O Connor, 1991). Psychotic relapse can cause significant personal distress, interfere with rehabilitation efforts, and result in psychiatric hospitalization (Lamberti, 2001). The psychotic symptom in this study defined as the positive symptoms, negative symptoms and affective symptoms. Therefore, the active symptom management is important in monitoring and decrease severity of psychotic symptoms in order to prevent symptom relapse (Baker, 1998; O Connor, 1994; Meijel, Gaag, Kahn & Grypdonck, 2003). The study suggested the need of effective nursing care to improve their abilities for self-managing symptoms. The purpose of this study is to evaluate the effect of the Symptom Self- Management Program (SSMP) on psychotic symptoms in schizophrenic patients compared with a routine care. The research hypothesis is the persons with multiple episode who received a SSMP would have significantly lower psychotic symptom than those who received usual care. Theoretical framework: Using knowledge from the vulnerability-stress model to understand the predicting factors to relapse and the self-management model to manage with these factors. Symptom self-management is the strategies that patients apply to control and decrease psychotic symptoms by using appropriate methods with existing resources (Kanfer, 1991) by actively involved in their own care, minimize stress on their living and foster are adaptation to life in the community, and continue antipsychotic medication to reduce and control psychotic symptoms and prevent psychotic symptoms (Birchwood, 2000; Lamberti, 2001; Meijel et al., 2003; McGlashan & Hoffman, 2000). The theoretical framework of the Symptom Self- Management Program on Psychotic Symptoms in this study is summarized in Figure 1. 2

Independence Phase I: The Problem Assessment and Needs Identification Session 1: - Establishing rapport with patients - Identify problems symptoms - Identify current symptom management techniques - Identify specific support systems Phase II: The Preparation for Symptom Self-management Session II & III: - Select symptom management technique - Establishing the goal to solve the problem - Providing information symptom self-management - Inform and educate patients about schizophrenia and the prescribed medication and its side effect - Listing EWS by the patient s perspective and the perspective of the healthcare professional(s) - Monitoring early warnings signs by instruct patients and the persons directly involved on how to monitor and evaluation early warning signs and provide guidance in actual monitoring process - Coping with early warning signs and practicing coping skill - Relevant source of stress and practicing coping skill Phase III: The Practice for Symptom Self-management Session IV& V: - Self-monitoring - Self-evaluation - Self-reinforcement Phase III: Evaluation for Symptom Self-management Session VI: Evaluation of the program and termination Dependence Decrease Psychotic symptoms Populations There were 80 eligible schizophrenic patients. The experimental group received a SSMP together with routine care, while the control group received only routine care. The criteria used to select the participants included adults Thai male or female age between 20 and 59 with multiple episode schizophrenic patients who have a history of 2 acute episodes in the past 5 years, outpatients complying with medical treatment, no history of drug and alcohol dependence, no diagnosed with brain dysfunction or cognitive impairments, able to read and write Thai and all participants agree to participate in the investigation, as expressed in the consent form. Criteria for exclusion from the study included receiving electro convulsion therapy, Brief Psychotic Rating Scale s score in more than 30 and unwilling to collaborate or participate in this intervention throughout the process. When schizophrenic patients whose characteristics met the inclusion criteria were selected for the study, investigator used random assigned to treatment condition by random number list of Statistical Package for the Social 3

Science for Window program (SPSS for Windows) and draw that number into group, in order to assignment the participants into either experimental or control group. Participants were recruited from an outpatients ward at Galya Rajanagarindra Institute, Bangkok, Thailand. Method The symptom self-management program referred to the strategy that schizophrenic patients apply to decrease the psychotic symptoms. This program was using the structured protocol of the Symptom Self-Management Program (SSMP). The SSMP based on the proposed of Kanfer (1991) included self-monitoring, self-evaluation, and self-reinforcement. This program was composed of four phase to manage psychotic early warning signs. This was 1) Problem Assessment and Needs Identification Phase 2) Preparation for Symptom Management Phase, 3) Practice for Symptom Management Phase, and 4) Evaluation for Symptom Management Phase. In phase 1 and 2 were implemented by group process and phase 3 and 4 were implemented by individual. The detail of the program was provided in Table 1. Table 1 The summarization of the intervention process PHASE CONTENTS METHOD SESSION&TIME Problem Assessment -Trust building - Group process - Session 1 & Need Identification - Introduction to the program - 60 minute - Mutual goal setting - Participation in process Preparation for - Schizophrenia & Psychotic - Group process - Session 2 Symptom relapse knowledge - Group teaching - 90 minute Self-management - Early warning signs - Group training - Session 3 management skill training - 90 minute - Information about the resources that effect the management Practice for - Self-monitoring - Daily self- monitoring form - Session4& &Symptom - Self-evaluation - Telephone follow up - Session 5 Self-management - Self-reinforcement - Individual counseling Evaluation for - Process evaluation - Daily self-monitoring form - Session 6 Symptom - Outcome evaluation - Participate with the researcher Self-management *session 4, 5 and 6 duration of time was depending on participations need. This study was the randomized control-group pretest-posttest design. The total number of participants who completed the program in each groups were 40 cases. The participants in 4

experimental group were dropped out 4 cases, 2 cases were failed to maintain follow up after finished the intervention and 2 cases could not complete the session, and in control group were also dropped out 4 cases, 2 cases refused to participate in the study and 2 failed to contact in follow up. The detail of sampling procedures is presented in Figure 2. 98 case notes screen from the patient s record file of out-patient wards Principal reason for exclusion (N = 88) 8 drug/alcohol dependence 2 refused to participate the study 88 fulfilled initial criteria Random sampling by SPSS program and random assign into group Experimental group (N=44) Complete trial (N= 40) Dropped out (N= 4) Control group (N=44) Complete trial (N=40) Dropped out (N=4) Figure 2 The details of sampling procedures The severity of psychotic symptoms was measured by the Brief Psychiatric Rating Scale (BPRS). The higher scores show the severity of the psychotic symptoms. As for using this instrument in this study, the content was validated by 5 experts, 1 physician, 2 nurse instructors, and 2 practical nurses. The inter-rater reliability between researcher and 2 expert psychiatric nurses was.89. In addition, the researcher was trained to use this instrument under supervisor of physician who an expert in this area. Data were collected twice: at the recruited date and about 10 weeks after the recruited date. The patients were interviewed about their personal information and the characteristic and severity of symptoms for the collection of data. The obtained data were analyzed with descriptive statistic Results: Most of the samples in this study were male (75%), were in the age group of 30-39 years (42.5%), single (58.75%), graduated from high school (38.75%), and unemployed (32.5%). In the control group, the majority of the subjects were almost male (67.5%), were in the age group of 30-39 years (40%), were single (55%), and unemployed (30%). There were the same percentages (32.5%) of the sample of graduated from elementary and high school. In the experimental group, the majority of the subjects were male (82.5%), were in the age group of 30-39 (45%), were single (62.5%), graduated from high school (45%), and unemployed 5

(35%) (Table 2). Chi-square test revealed no statistically significant difference between the control and the experimental group regarding gender, marital status, education, occupation, but there was statistically significant different in age group of the control and the experimental group (p-value=.03). Therefore, the ANCOVA would be conducted for data analysis. Table 2 Demographic characteristic of the samples Characteristics Gender Control Experimental Total χ 2 (df) p-value N % N % N % Female 13 32.5 7 17.5 20 25 2.40(1) 0.12 ns Male 27 67.5 33 82.5 60 75 Age 20 29 years 5 12.5 14 35 19 23.75 9.16(3) 0.03 * 30 39 years 16 40 18 45 34 42.5 40 49 years 12 30 6 15 18 22.5 50-59 years 7 17.5 2 5 9 11.25 Marital Status Single 22 55 25 62.5 47 58.75 0.46(2) 0.79 ns Married 11 27.5 9 22.5 20 25 Widow/ divorce/ Separate Occupation 7 17.5 6 15 13 16.25 Office Staff 11 27.5 9 22.5 20 25 1.86(2) 0.39 ns Labor for hire and Farmer 14 35 10 25 24 30 Student and Unemployment 15 37.5 21 52.5 36 45 Education Elementary 13 32.5 13 32.5 26 32.5 2.06(3) 0.56 ns Secondary 5 12.5 4 10 9 11.25 High school 13 32.5 18 45 31 38.75 Diploma/Bachelor 9 22.5 5 12.5 14 17.5 p<0.05 ns = no significant * = significant The demographic characteristic of control group and experimental group on number of receiving treatment and duration of having illness revealed that the characteristics of the control and the experimental group. Number of receiving treatment characteristic, the total 6

participants number of receiving treatment ranged from 2 times to 5 times ( X =2.45; SD=0.73). In the control group, the number of hospitalization ranged from 2-5 times ( X =2.40, SD=0.67). As for the experimental group, the number of hospitalization ranged from 2-5 times ( X =2.50, SD=0.78). Duration of having schizophrenia in the total participants ranged from 1-5 years ( X =3.23, SD=1.54) like the experimental group, the duration of having schizophrenia ranged from 1-5 years ( X =3.36, SD=1.56) (Table 3). Table 3 Demographic characteristic of control group and experimental group: Number Characteristics Number of receiving treatment and Duration of having illness of Total Control Experimental t-test df p-value Mean SD. Mean SD. Mean SD. hospitalization 2.45 0.73 2.40 0.67 2.50 0.78 0.61 78 0.54 Duration of having schizophrenia 3.23 1.54 3.10 1.53 3.36 1.56 0.78 78 0.44 The table 4 revealed that mean total scores of pretest in positive symptoms, negative symptoms, affective symptoms and total score were 11.63 (SD.=2.18), 7.89 (SD.= 2.30), 7.46 (SD.= 2), and 26.98 (SD. = 3.49), respectively. The mean total score of post test in positive symptoms, negative symptoms, affective symptoms and total score were 14.88 (SD.= 6.14), 8.75 (SD.= 3.43), 9.93(SD.=4.55), 33.55 (SD.=12.10), respectively. This table showed the mean score of psychotic symptom in positive, negative and affective symptoms between the control and experimental groups in pretest were similar, but in posttest means scores of all psychotic symptoms in the experimental had lower than in that control group. Table 4 The comparison of positive symptoms, negative symptom and affective symptoms between control group and experimental group at the pretest and posttest BPRS Scores Total Control Experimental Mean SD. Mean SD. Mean SD. Pretest Positive symptoms 11.63 2.18 11.65 2.09 11.60 2.28 Negative symptoms 7.89 2.30 7.50 1.99 8.28 2.54 Affective symptoms 7.46 2.00 7.80 1.94 7.13 2.03 Total 26.98 3.49 26.95 3.28 27.00 3.72 Posttest Positive symptoms 14.88 6.14 16.68 6.60 13.08 5.11 Negative symptoms 8.75 3.43 10.83 3.36 6.68 1.94 Affective symptoms 9.93 4.55 12.33 3.83 7.53 3.92 Total 33.55 12.10 39.83 11.06 27.28 9.68 7

ANCOVA was used to test the hypothesis with group assignment (experimental or control) as the independent variable, age as the covariate variable, and psychotic symptom as the dependent variable. After adjusting for psychotic symptom by controlling age, there were significantly differences in psychotic symptoms between group ((p=.000). Patients in the experimental group (mean=27.28, SD=9.68) had lower psychotic symptom than those in the control group (mean=39.83, SD=11.06). (Table 5) Table 5 Comparison of psychotic symptom between the experimental and control groups by controlling age Source SS df MS F P Covariate.147 1.147.001.971 Between group (Adjust) 2795.626 1 2795.626 25.579.000* Within group (Error) 8415.603 77 109.294 Total 101614.000 80 *p<0.05 Discussion The principal findings of this study were the experimental group which receiving SSMP were significant statistical lower psychotic symptoms than the control group. The program was designed to empower the patients to gain the ability to decrease psychotic symptoms. The participants who receiving the program in 6 sessions experienced decrease in positive symptoms, negative symptoms and affective symptoms. The improvement experienced by participants in this study involved less psychotic symptoms and the individual feeling more control over their psychotic symptoms. The patient-based nursing intervention of the program did facilitate the empower process in accordance with the individual problems and needs which increase the patient s self-ability. This program was different from routine care currently provided in the most clinics which this care was mostly disease-orientated and emphasized the collective symptoms of the disease while individual problems were neglected. Therefore, assessment of problems, needs, ability to manage the symptoms and setting of the self-management goal were mutually conducted between the patient and nurse. Through this mutual process were empowered patients to increase self-ability management with his/her symptoms. This study confirmed that promoting self-management for patients with schizophrenia able to decrease the psychotic symptom. These changes in self-ability to efficiently care for his/her symptoms results from the participants learning and practicing skills for managing their early symptoms in a group setting and then practicing those skill daily in their real life at their home by themselves. The results congruent with Heinssen et 8

al. (2000), who reported that homework at home helps (p.40), with the work of Liberman (1988), who found that once learned, skills are often maintain often time. The SSMP demonstrated effects in reducing the characteristic and severity of early warning signs in outpatients diagnosed with schizophrenia. The SSMP provided knowledge and skill of symptom self-management concerning self-care management from the actual experience of schizophrenia, the self-management for the psychotic symptoms and increased the patient s symptom self-management ability. These result congruent with previous studies (Buccheri et al., 1997; Trygstag et al., 2002; Kanungparin et al., 2007). They stated that for effective symptom self-management strategies, the patients needs to learn about the disease and to understand the symptoms, including perceiving the symptom, being able to assess the severity of the symptoms and its threat to life, recognizing their emotional and behavioral response to the symptoms, practice the skills to manage the symptoms, and evaluating the outcome. Direction for future research The major limitations of this study were a short term of follow up and a moderately small sample of outpatients with schizophrenia (n=80) (although large enough to demonstrate significant). Another limitation is that group sessions were conducted by one leader. In the future, there is a need to test program where many individuals serve as leaders so the issue of leadership style/characteristics can be included in the evaluation of the methods. Acknowledgements The researcher would like to thank Graduate School, Chulalongkorn University and Health Development Center for Persons with Chronic Health Problem, Faculty of Nursing, Chulalongkorn University. 9

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