Rehabilitation model in the therapeutic community
This study was conducted in a psychiatric hospital, Yuli Hospital, Ministry of Health and Welfare, with approximately 2000 patients receiving humanistic and patient-centered professional care in eastern Taiwan. The patients in the therapeutic community at the hospital had greater access to occupational rehabilitation and worked outside the hospital while they were stable. The therapists in this therapeutic community trained the appropriate patients regularly and encouraged them to be employed in the outside labor market. This multidisciplinary rehabilitation model consisted of identifying patients’ advantaged ability, matching appropriate employment, and negotiating with employers to get reasonable salaries, especially in supported and sheltered employment. In general, the salary has remained at a fixed rate for a given job, according to predetermined agreement with employers. However, the salary may be adjusted according to a patient’s actual performance, such as efficiency, regularity, and punctuality in the workplace, based on a predefined contract among three parties: the patient, the occupational therapists, and the employers. All occupational therapists and employers reached a consensus to assist the workers according to the same standard, that is, harboring impartiality in the acceptance of workers and avoiding undue tolerance of misconduct, unjustified monetary rewards, and unreasonable harsh requirement toward the workers. If a patient expressed unwillingness to keep his or her current job, or if there were signs of unstable psychiatric condition, the intervention procedures, such as transient cessation of jobs, adjustment of medicine, or psychiatric counseling, were started. After the intervention, if the patient was still unable to meet the requirement of current work, he or she was exempted from current jobs, and the possibility of shifting to other sheltered jobs or workshops was discussed in the team meeting.
Participants
All 550 residents in the therapeutic community of Yuli Hospital from January 2013 to December 2015 were recruited for this study. Inclusion criteria were as follows: patients who were diagnosed with schizophrenia or schizoaffective disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Text Revision, Fourth Edition. Exclusion criteria included: (1) those who had an acute psychotic episode requiring transfer to acute psychiatric wards at the stage of enrollment, (2) those who refused to provide consent for evaluation, and (3) individuals with significant cognitive deficit (e.g., delirium or dementia). After the content of study procedures, benefits, and risks were fully explained to patients, informed consents were obtained. All patients who signed the informed consent underwent an initial evaluation for 1- to 2-year follow-up assessments regarding related clinical data and employment outcomes.
Measurements of independent variables and outcomes
Demographic data, including age, sex, educational years, age at schizophrenia onset, and types and defined daily dose of antipsychotics on recruitment were abstracted from the medical records of the patients. The antipsychotics were categorized into typical antipsychotics (TAs), non-clozapine atypical antipsychotics (NCAAs), and clozapine. Patients concurrently using TAs and NCAAs were categorized as NCAAs users. Those who concurrently used clozapine and two other types of antipsychotics were categorized as clozapine users. The antipsychotics were categorized, and their dosages were converted to a defined daily dose (DDD) of antipsychotics according to a prior study [30] and from information available on the website of the Collaborating Center for Drug Statistics Methodology of the World Health Organization (http://www.whocc.no/atc_ddd_index/).
Positive and Negative Syndrome Scale (PANSS)
The psychopathology of each patient was assessed using the Chinese version [31] of the PANSS [32](CMV-PANSS) at baseline. The PANSS ratings were based on patient interview and on information from other caregivers. This evaluation was conducted on the basis of an absolute threshold of severity for the following eight core symptoms: delusions (P1), conceptual disorganization (P2), hallucinatory behavior (P3), blunted affect (N1), social withdrawal (N4), lack of spontaneity (N6), mannerisms/posturing (G5), and unusual thought content (G9).
Symptomatic remission
Symptomatic remission as defined by the RSWG in 2005 was evaluated by 4 board-certified psychiatrists using the CMV-PANSS [6]. Patients were identified to be in the state of symptomatic remission when each one of the scores of the aforementioned eight items of CMV-PANSS was less than 3 and the condition remained stable for at least 6 months. The CMV-PANSS was assessed only before the enrollment. For each patient, medical records and observation provided by medical personnel compassing 6 months before the enrollment were examined. During the period of 6 months, stable clinical condition was defined as (1) participants did not have dominant fluctuation of psychiatric symptoms needing adjustment of psychotropic agents or (2) no transfer to or referral from acute psychiatric wards. For those whose scores on the eight items of the CMV-PANSS were less than 3 with a stable condition lasting for 6 months, the status of symptomatic remission was judged.
Mini-Mental State Examination (MMSE)
The Chinese version [33] of the MMSE [34] is a 33-point questionnaire used extensively in clinical and research settings to measure cognitive function. It is 3 points greater than the original version since the Chinese version added 3 questions to increase the discriminant validity in a population with relatively few years of education. Higher scores indicate better cognitive function.
ADL and IADL
For each patient, the IADL and ADL ratings were conducted by the patient’s charge nurse based on clinical observation and information from other caregivers. The Barthel index [35] was used for evaluating 10 variables describing ADL (feeding, bathing, dressing, toilet use, presence or absence of fecal or urinary incontinence) and mobility (transferring, walking, and climbing stairs). The Chinese version [36] of the IADL scale [37] was used to evaluate the patients’ ability to live independently in a community. This scale can measure competence in managing complex ADL, such as medication management, shopping, transportation, laundry, and social interaction. The maximum total IADL scale score is 24. The score for each IADL item ranges from one to three (1 = the patient cannot perform a specific activity at all, 2 = the patient can perform it with help or supervision, and 3 = the patient can perform it independently).
Rating procedure
All raters, including one certified psychiatric nurse (Y.H.Y.) and three board-certified psychiatrists (C.H.Y., B.J.W., and S.U.), who had reached a high standard of interrater reliability (intraclass correlations ranged from 0.86-0.95) with the gold-standard raters from the Yuli Hospital research group, rated the PANSS and MMSE. The IADL and ADL scores were available from the database in the nursing department of the hospital, which required charge nurses to conduct regular evaluation with an adequate interrater reliability. All details of the interrater reliability of these ratings were described in prior studies [23, 31].
Initial type of employment
The participants received occupational rehabilitation in three types of employment, including (1) the hospital-based workshop (N = 323), which provides simple and repeated activities to develop work potential in patients with stable psychiatric symptoms; (2) sheltered employment (N = 68), which provides a protective workplace for the patients with work potential who cannot work in a competitive workplace, such as in a working team for cleaning (N = 37), cook assisting (N = 16), car washing (N = 8), or others (N = 7); and (3) supported employment (N = 134), which has been reported to be highly effective for patients to achieve competitive employment in regular employment in an integrated community setting [25], such as house cleaning (N = 61), document delivery (N = 34), elder care (N = 19), guarding (N = 12), painting (N = 3), and others (N = 5).
Employment outcomes
Employment outcomes as dependent variables, defined as the cumulative on-the-job duration (months/per year) and income (NT$/per year), were calculated in the first and second year after entry in this study. There were two time points for collection of outcomes: (1) Time 1: 1 year after the entry and (2) Time 2: 2 years after the entry. Dependent variables of Time 1 were cumulative employment duration and incomes from the entry of this study to Time 1. Dependent variables of Time 2 were cumulative employment duration and incomes from Time 1 to Time 2.
Statistical analysis
Participants were excluded from the regression model analysis if they met following conditions during the study: (1) they were proclaimed dead, (2) they were discharged to their home, (3) they were transformed from remission at baseline to acute relapse which required transferal to acute psychiatric wards afterwards. For patients with symptomatic remission at baseline, whether there were significant differences in variables between those who encountered acute psychotic relapse and those who did not would be examined.
For repeated measurements within individual patients, the association between symptomatic remission and employment outcomes was investigated using a mixed-effects model analysis [38]. Potential covariates, including age, sex, educational years, type and daily dose of antipsychotics, cognitive function, initial employment type, ADL and IADL were controlled for.
All independent variables were assessed once at the baseline except for ADL and IADL which were repeatedly collected. For ADL and IADL, their time points were (1) Time 1: at the entry of the study and (2) Time 2: 1 year after study entry. For finding factors related to employment outcomes in patients without remission, aforementioned regression models were conducted after stratifying remission status. All analyses were conducted using IBM statistics SPSS, version 19.0, and the significance level was set at two-tailed p < 0.05.