The aim of the study was to evaluate the effectiveness of CRP on therapeutic variables during hospitalization period in patients with schizophrenia spectrum disorders and compare it with conventional psychiatric treatment of these patients in Raazi Psychiatric Hospital. In general, the results showed that compared with conventional psychiatric treatment of patients with schizophrenia spectrum disorders, the simultaneous implementation of conventional psychiatric treatment and CRP was more effective on the therapeutic outcomes during hospitalization period. The findings are consistent with the results of previous studies in the field (Arab Ghahestany et al., 2018; Okanli et al., 2017; Jamshidi et al., 2017a; Xiang et al., 2007; Liberman et al., 1998).
A closer look at the results of this study showed that as a result of incorporating the CRP into conventional psychiatric treatment, there was a significant difference between experimental and control groups in the variables of positive and negative syndrome (by modulating the effect of the pre-test) and the two variables of PRN and physical restraint frequency, meaning that patients who participated in CRP in addition to conventional psychiatric treatment showed a greater reduction in the above variables than patients who received only conventional psychiatric treatment. But despite the observed difference in the mean scores of variables of adhesion and duration of hospitalization in the two groups, these differences were not significant. In the following, we explain each of these findings, respectively.
The results showed that there was a difference in the positive syndrome variable between the participants of the experimental and control groups, that although was not large, but even this small difference was significant. In this regard, it should be noted that the signs and symptoms classified under the label of positive syndrome are inherently among the ones that are rightly the subject of medication, and at least in our country there is little reliance on the use of non-pharmacological strategies to treat them (Arab Ghahestany et al., 2018). It is also not expected that non-pharmacological approaches, especially approaches based on psychoeducation, can be effective in controlling these signs and symptoms that are characteristic of schizophrenia and other severe psychiatric disorders and are among the most troublesome psychiatric signs and symptoms (Jamshidi et al. 2017b). However, this finding clearly shows that even in the control and treatment of signs and symptoms that have long been the subject of medication, the effectiveness of non-pharmacological treatment approaches should not be overlooked, because despite the success of medication in controlling positive syndrome and its significant effectiveness in this context, incorporating non-pharmacological approaches such as CRP into pharmacological approaches can be effective in strengthening the effectiveness of these approaches, and further reduces the positive syndrome, which in turn play a role in improving the treatment outcome and controlling the disease faster and more effectively; because such an intervention is effective in increasing patients' information and improves their therapeutic attitude and adherence (Arab Ghahestany et al., 2018). Given the fact that the effectiveness of the CRP on this dependent variable has been confirmed in many studies (the findings of Armijo et al., 2013; Xiang et al., 2007; Xiang et al., 2006; Anzai et al., 2002 And Jamshidi et al., 2017a, on the effectiveness of CRP on reducing positive syndrome; and the findings of Granholm et al., 2005 and Bastillo et al., 2001, on the effectiveness of psychosocial therapies on reducing these symptoms); lack of effectiveness confirmation of the intervention program on positive syndrome in a few studies conducted in our country (Jamshidi et al., 2017b; and Mohammadzadeh Nanehkaran et al., 2013), can be due to reasons such as methodological problems, difficulty in correct implementation of the CRP, and also the research samples differences.
The therapeutic variable of negative syndrome also decreased more in the experimental group compared to the control group, but the importance of the finding becomes more when we consider that the negative syndrome is not much affected by medication (Armijo et al., 2013). In other words, medication is not an appropriate therapeutic approach to reduce the negative signs and symptoms, and this point can be well seen in the observed difference in the scores of negative syndrome in the experimental and control groups. Given that negative symptoms are mainly related to loss of skills and decline in function (Gale, 2008), it is not unreasonable to expect that medication can have little effect on reducing them because, skill training and performance improvement are in the area of rehabilitation, that is outside the scope of pharmacotherapy and addressing it requires the use of non-pharmacological interventions, and for this reason, the implementation of the CRP has been able to cause such a difference in this variable, and like many studies in the field (Armijo et al., 2013; Xiang et al., 2007; Xiang et al., 2006; Anzai et al., 2002; Jamshidi et al., 2017b; and Mohammadzadeh Nanehkaran et al., 2013, on the effectiveness of CRP in reducing negative syndrome; and Bastillo et al., 2001, on the effectiveness of psychosocial therapies on reducing these symptoms), emphasizes the need to complement medication with non-pharmacological therapies such as CRP. Reducing negative syndrome increases quality of life and personal function, improves social and interpersonal relationships, and increases self-management, which in turn improves treatment outcomes and increases the patient's ability to remain in the community and is therefore, one of the most important therapeutic goals.
Regarding the variable of PRN frequency, a significant positive effect was observed as a result of implementing the CRP. In other words, the difference between the participants in the experimental and control groups in terms of the number of times they received PRN was significant and showed that patients who participated in the CRP in addition to conventional psychiatric treatment, were in a much better position in this regard than patients who received only conventional psychiatric treatment, regarding the observed difference in the mean number of times they received PRN (2.56 in the experimental group vs. 4.06 in the control group). A very important and new finding in this study.
Implementation of CRP also showed a positive and significant effect on reducing the frequency of physical restraint. In other words, the difference between the participants in the experimental and control groups in terms of the number of times they received physical restraint was significant and showed that patients who participated in CRP in conjunction with conventional psychiatric treatment were much better in this regard than patients who received only conventional psychiatric treatment, regarding the observed difference in the mean number of times they were physically restrained (0.86 in the experimental group vs. 1.70 in the control group). This point was also an important and new finding in this study.
PRN and physical restraint, by their definitions (Sadock et al., 2015) are invasive interventions that are carried out forcefully and against the patient's will, and as a result can have a negative impact on patients' attitudes toward treatment and hospitalization, as well as their participation and cooperation in the treatment process (this effect is more severe in the case of physical restraint) (Arab Ghahestany et al., 2018). But the important point to note is that, unlike medication, which is a necessary therapeutic intervention, the nature of these controlling therapeutic interventions is such that the conditions can be provided in such a way that there is no need to administrate them. In other words, to eliminate their necessity, the emergence of psychiatric emergencies must be prevented. Conventional psychiatric treatment can prevent many of these emergency situations that caused by disorder’s symptoms (mainly positive symptoms and other psychological factors). although psychosocial treatment approaches have also a proven effect on many of these symptoms, including delusions, mood and anxiety problems, etc., Abbasi et al., 2019, 2020; Armijo et al., 2013). However, some of these situations occur as a result of negative symptoms or, in better words, lack of skills; which, as mentioned earlier, can’t prevented using conventional psychiatric treatment, and this is the reason for the significant difference observed in this part of the present study. Therefore, to compensate for the weakness, it is necessary to complement conventional psychiatric approaches using non-pharmacological approaches, such as CRP, in which, the skill training aspect is highly emphasized.
Therefore, the findings of this part of the study clearly show that the implementation of non-pharmacological treatment approaches such as CRP can well cover the weakness of medications in reducing the incidence of situations that necessitate invasive interventions such as PRN and physical restraint for patients, and highly reduce the frequency of such interventions, that have a negative impact on the patients treatment process and their relationship with the treatment staff and cause a negative attitude in them toward treatment and reduce their cooperation in the process, as well as, emphasize the need to complement medication with non-pharmacological treatment approaches.
Based on the findings of the study, the implementation of CRP could not have a significant effect on duration of hospitalization and adhesion rate, and there was no significant difference in these two variables between the experimental and control groups. This finding was inconsistent with findings of Armijo et al. (2013) on the effectiveness of community-based interventions on reducing duration of hospitalization.
But what could be the probable cause of the finding? At first glance, it seems that the implementation of the CRP could not reduce the duration of hospitalization, but if we look more closely at the issue, considering the other variables studied in this study, such as positive and negative syndrome and frequency of PRN and physical restraint, It is clear that, in fact, patients are usually and conventionally discharged very early, before their symptoms are fully controlled and become ready to be discharged, which causes their disorder to relapse very quickly and be re-admitted to the hospital. However, if the patients' discharge time, or more accurately, the goal of their treatment, is determined realistically, and patients who are receiving conventional psychiatric treatment are discharged when they become equally recovered and controlled as patients who are receiving complementary CRP, then their duration of hospitalization becomes much more longer, and even may never reach the level of recovery needed for discharge and remain in the hospital permanently.
Regarding the frequency of adhesion, considering that the adhesion mean score of the participants in the experimental and control groups was different (2.44 vs. 2.94) but the difference was not significant, it can be concluded that the effect of CRP on the adhesion rate was likely a delayed one, in the sense that it appeared gradually and after a period of time from the start of treatment, and perhaps if, based on what was said about the duration of hospitalization, the time of discharge in the conventional psychiatric treatment group was realistic, the difference would increase and reach a significant level, although even now it has made a difference of about 17 percent. But this conclusion is purely probabilistic and should be considered in future research.
Therefore, if we look at the findings of this part of the study from this point of view, we will see that the implementation of CRP has reduced the length of hospitalization needed to improve patients with schizophrenia and therefore, it can be clearly claimed that incorporating non-pharmacological therapeutic approaches in conventional psychiatry treatment can reduce both the length of hospitalization of psychiatric patients and the staggering costs of their hospitalization, which, along with a decrease of approximately 17 percent in the frequency of adhesion due to the implementation of CRP in the experimental group compared to the control group (although was not statistically significant), is worth noting and emphasizes the need to complement medication with non-pharmacological therapeutic approaches such as CRP.