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Original Article

 

EFFECTS OF PAID WORK ASSIGNMENTS ON PSYCHOPATHOLOGY
IN HOSPITALIZED CHRONIC SCHIZOPHRENIC PATIENTS

Kumar S, 1 Mohanty S. 2

1Director, 2Research Officer, Institute of Mental Health and Hospital Agra.

Abstract

Background People with schizophrenia want to work but face many barriers when returning to work. Many factors such as demands of the labor market, work restrictions caused by illness, complications associated with disability benefits, limited availability of evidence-based programs contribute to poor employment

AimThe present study explored contribution of paid work assignments on psychopathology of hospitalized chronic schizophrenic patients.

Method 200 chronic schizophrenic patients were drawn in two groups (a) Experimental (n=100) (b) Control (n=100) from in-patients of Institute of Mental Health and Hospital, Agra. Between group repeat measures design was used in this study. Both the groups were engaged in different activities but payment was made to only experimental group. Scale for Assessment of Negative Symptoms (SANS).and Scale for Assessment of Positive Symptoms (SAPS) were used to measure Negative as well as Positive symptoms. The data were organized and processed in SPSS 11.5 version for relevant statistical analysis. Mean, S.D., chi-square, ANCOVA and charts were used to analyze and present the data. ANCOVA was used to cancel out the effects of baseline differences in scores and estimate group differences.

Result the result was shows that significant contribution of paid work activities in improving psychopathology.

Conclusion The pattern of longitudinal assessments revealed that both the groups improved but the paid group had greater improvement.

Key Words Vocational Rehabilitation, Chronic Schizophrenia, Paid Work and Severe Mental Illness

Introduction

Employment or work is considered as one of the major areas of functioning in the rehabilitation of mentally ill persons, specifically with schizophrenia. Having a mental illness is a critical concern for people with severe mental illness when seeking employment1. People with schizophrenia want to work but face many barriers when returning to work. Many factors such as demands of the labor market, work restrictions caused by illness, complications associated with disability benefits, limited availability of evidence-based programs contribute to poor employment2. Despite of barriers vocational rehabilitation has been shown to improve employment rates for individuals with schizophrenia and a variety of vocational rehabilitation interventions have been developed over the past few decades to enhance the vocational capacities of persons with this disorder. Researchers in recent years have explored different approaches to vocational rehabilitation including skills training methods, sheltered workshops, transitional employment, and supported employment1,2.

Among the factors psychopathology is considered as a prominent one for job continuity. Prior researches attended the relationships between psychopathology and vocational functioning. Brier3 observed that quantity of work was related to improvements in both positive and negative symptoms. In another study4 correlated negative symptoms and work functions. Their results showed that the participants with prominent negative symptoms demonstrated poorer performance on task orientation and also reported that work therapy program is related to decrease in symptoms of emotional discomfort and hostility.5 Psychopathological indicators proved to be the best predictors of work performance both cross-sectionally as well as in the long term course6,7,8 and work participation was related to reduction in thought disorder.8

Schizophrenic symptoms were not significantly associated with functional outcome.9This is particularly more so for positive symptoms as compared to negative symptoms where some studies found negative symptoms but not positive symptoms to be associated with unemployment in schizophrenia3,10,11 Negative symptoms were related to hours, weeks, and wages earned on the job13 another study it was found that significant negative correlation of social functioning with positive symptoms, negative symptoms, and general psychopathology in patients with vocational rehabilitation.20 On the  PANSS and general psychopathology scale shows that disability in work performance is correlated with mean scores on.23 Vocational rehabilitation significantly improved negative symptoms and in quality of life18.

In a recent study reported that there was no significant association between overall psychopathology, positive or negative symptoms and employment.19 Role of symptoms in employment have been inconsistent with more studies showing negative symptoms but not positive symptoms as significant correlates of employment14,15 and conducted a review that identifies person-related factors which most strongly influence employment outcomes and found better social functioning.16 Findings on the severity of psychiatric symptoms measured during PVR were mixed. In terms of contribution to outcome, severity of symptoms usually ranked below work performance, when measured concurrently.

Aim

To study the effects of remunerative job on psychopathology of hospitalized chronic schizophrenic patients:

Method

Design between Group Repeat Measures

Venue This study is a part of an ICMR sponsored research project being carried out at Institute of Mental Health and Hospital, Agra.

Sample A sample of 200 chronic schizophrenic patients was drawn in two groups (a) Experimental (n=100) (b) Control (n=100) from in-patients of Institute of Mental Health and Hospital, Agra. Following inclusion/exclusion criteria was adopted to recruit the patients.

·         The diagnosis of Schizophrenia as per ICD – 10: Research Diagnostic Criteria (WHO, 1993)

·         The patients with at least two years continuous duration of illness

·         Co-operative and communicative patients who did not have management problems

·         The age range of the participants: 20-55 years

·         The written informed consent from the patients

·         The patients having co-morbid psychiatric conditions; mental retardation, organic disorder and major physical illness were excluded.

Tools

Scale for Assessment of Negative Symptoms (SANS)24 SANS assesses five symptom complexes to obtain clinical ratings of negative symptoms in patients with schizophrenia. They are: affective blunting; alogia (impoverished thinking); avolition/apathy; anhedonia/asociality; and disturbance of attention. The final symptom complexes seem to have less obvious relevance to negative symptoms than the other four complexes. Assessments are conducted on a six-point scale (0=not at all to 5=severe)

Scale for Assessment of Positive Symptoms (SAPS) 25 this scale is designed to assess positive symptoms, principally those that occur in schizophrenia. It is intended to serve as a complementary instrument to the Scale for the Assessment of Negative Symptoms (SANS). These positive symptoms include hallucinations, delusions, bizarre behavior, and positive formal thought disorder.

Procedure

After obtaining informed consent, the suitability of the patients was determined as per the inclusion criteria listed above. The screened in participants were included and allocated to experimental and control groups. Their identifying details were recorded on a separate proforma.

Baseline Phase In this phase the screened in participants were assessed on SANS and SAPS by Senior Research Fellow

Job Assignment and Training Following occupational activities (1) Ward Activities (2) Agriculture and Nursery. (3) Production Units (candle making, envelope making, Tailoring, Spiral Binding, dona making, Weaving, Carpentry, Knitting, door mat making, stitching and embroidery). (4) Patients’ Kitchen (5) Campus Maintenance etc. were available to the patients in the Institute. The patients were placed in these activities on the basis of their level of functioning, occupational background and patients’ own willingness to work in these activities.

The participants of both the groups were trained on the spot to perform the selected tasks if required. The training was mostly provided by the vocational instructors of the Institute who are engaged in the units. The duration of the remunerated assignment was approximately 3 hours per day. Each participant of experimental group was credited with the remuneration @ Rs. 25/- per day. The logbook of the assignments and accrued remuneration were maintained by the project staff. The maximum duration of remunerative job for a participant was kept fixed for 50 days in approximately two months. The disbursement of the remuneration was done by the Finance Department of the Institute. The pharmacological regimen continued as per the requirement and prescription of the treating clinician.

First Assessment (Baseline) the first assessment at the time intake to the patient.

Second Assessment This assessment was conducted at the end of one month after commencement of training.

Third Assessment This assessment was conducted at the end of two months after commencement of training.

Follow up Phase The participants did not receive any remuneration during this phase. If hospitalized they continued to perform the assigned tasks.

The pharmacological regimen continued. The assessment were conducted at following points irrespective of institutional status of the participants

First follow up (Fourth Assessment): 3rd month of baseline

Second follow up (Fifth assessment):6th month of baseline discharged patients were followed in OPD. Those who did not report in OPD for follow up, were contacted through phone and invited to the Institute for follow up assessments. They were paid travel expenses for the same.Data Analysis The data were organized and processed in SPSS 11.5 version for relevant statistical analysis. Mean, S.D., chi-square, ANCOVA and charts were used to analyze and present the data. ANCOVA was used to cancel out the effects of baseline differences in scores and estimate group differences


 

Results

Table-1: Sample Characteristics

Characteristics

Experimental Group (n=100)

Control Group

(n=100)

t-values/ χ˛ Values

Age (in years)

34.55 ±8.84

33.42±7.66*

0.33

Duration of Schizophrenic Illness (in years)

8.26±4.83

8.85±4.52*

0.37

Gender

Male

80

81

Female

20

19

 

Education

Nil

8

23

Upto H.Sc

68

45

 

Above H.Sc

24

32

 

Domicile

Rural

53

61

Urban

47

39

 

Marital Status

Married

64

73

Unmarried

36

27

 

SES

High

2

2

Middle

71

59

 

Low

27

39

 

Family H/O Psychiatric Illness

No

77

72

Yes

23

28

 

*Significant at .01 level

 

Chi-square and t-tests were computed to examine group differences on sample characteristics. Table-1 indicates that both the groups were comparable on most of the variables except Education; the control group had higher illiterate participants.

Comparison of Total Experimental and Control Group on SANS Figure-1 depicts mean scores on SANS across phases. It clearly reveals that there were little differences at baseline in two groups but on second assessment marked differences emerged in two groups which were maintained over subsequent assessments. The experimental group had lower scores.

Table-2: Mean and S.D. of SANS Scores across phases

Assessment Phases

Groups

N

Mean

SANS-First Assessment (Baseline)

Experimental

100

9.83

Control

100

10.57

SANS-Second Assessment

Experimental

100

6.11

Control

99

8.41

SANS-Third Assessment

Experimental

100

2.61

Control

99

7.68

SANS-Fourth Assessment

Experimental

100

2.41

Control

98

6.78

SANS-Fifth Assessment

Experimental

100

2.24

Control

98

6.21

 

Table-3: Results of One Way ANOVA for SANS Scores across phases

Assessment Phases

Sources

Sum of Squares

df

Mean Square

F

Sig.

SANS-First Assessment (Baseline)

Between Groups

27.380

1

27.380

.808

.370

Within Groups

6712.620

198

33.902


 

 


 

 

Total

6740.000

199


 

 


 

 


 

 

SANS-Second Assessment

Between Groups

264.119

1

264.119

10.868

.001

Within Groups

4787.810

197

24.304


 

 


 

 

Total

5051.930

198


 

 


 

 


 

 

SANS-Third Assessment

Between Groups

1277.156

1

1277.156

55.819

.001

Within Groups

4507.447

197

22.880


 

 


 

 

Total

5784.603

198


 

 


 

 


 

 

SANS-Fourth Assessment

Between Groups

943.259

1

943.259

47.831

.001

Within Groups

3865.251

196

19.721


 

 


 

 

Total

4808.510

197


 

 


 

 


 

 

SANS-Fifth Assessment

Between Groups

781.770

1

781.770

46.535

.001

Within Groups

3292.740

196

16.800


 

 


 

 

Total

4074.510

197


 

 


 

 


 

 

 

The mean and SD score of paid group at Baseline(First Assessment) are M=9.83 S.D.= 6.122 and non paid group are M=10.57 S.D.= 5.507 (Table-2) ,F (1,198)=.808, p=.370; Partial η2 = .004}(Table-3). In Second Assessment mean and SD score of paid group M=6.11 S.D.=4.452 and non paid group M=8.41 S.D.= 5.370 (Table-2)F(1,97)=10.858, p=.001; Partial η2 = .052}}(Table-3). In Third Assessment the mean and SD score of paid group M=2.61 S.D.=3.467; and non paid group are M=7.68 S.D.= 5.818 (Table-2) F(1,197)=55.819, p=.001; Partial η2 = .221}(Table-3) In Fourth Assessment the mean and SD score of paid group M=2.41 S.D.=3.220; and non paid group are: M=6.78 S.D.=5.410(Table-2) F(1,196)=47.831, p=.001; Partial η2 = .196)(Table-3); and In Fifth Assessment the mean and SD score of paid group M=2.24 S.D.=2.843; and non paid group are M=6.21 S.D.=5.069(Table-2) F(1,196)=46.535, p=.001; Partial η2 = .192}(Table-3)

 

The above scores indicate no significant group differences in SANS scores of baseline and statistically significant differences in subsequent assessment (Table-2). . The experimental group scored significantly lower than the control group (Table-3).

Comparison of Total Experimental and Control Group on SAPS Figure-2 depicts mean scores on SAPS across phases. It clearly reveals that there were little differences at baseline in two groups but on second assessment marked differences emerged in two groups which were maintained over subsequent assessments. The experimental group had lower scores.

Table-4: Mean and S.D. of SAPS across phases

Assessment Phases

Groups

N

Mean

SAPS- First Assessment (Baseline)

Experimental

100

8.88

Control

100

9.41

SAPS-Second Assessment

Experimental

100

4.01

Control

99

7.33

SAPS-Third Assessment

Experimental

100

1.79

Control

99

6.83

SAPS-Fourth Assessment

Experimental

100

1.78

Control

98

6.04

SAPS-Fifth Assessment

Experimental

100

1.78

Control

98

5.68

 

Table-5: Results of One Way ANOVA for SAPS across phases

Assessment Phases

Sources

Sum of Squares

df

Mean Square

F

Sig.

SAPS-First Assessment (Baseline)

Between Groups

14.045

1

14.045

.525

.470

Within Groups

5296.750

198

26.751

 

 

Total

5310.795

199

 

 

 

SAPS-Second Assessment

Between Groups

549.452

1

549.452

30.143

.001

Within Groups

3590.990

197

18.228

 

 

Total

4140.442

198

 

 

 

SAPS-Third Assessment

Between Groups

1262.837

1

1262.837

80.650

.001

Within Groups

3084.671

197

15.658

 

 

Total

4347.508

198

 

 

 

SAPS-Fourth Assessment

Between Groups

898.559

1

898.559

53.256

.001

Within Groups

3306.997

196

16.872

 

 

Total

4205.556

197

 

 

 

SAPS-Fifth Assessment

Between Groups

754.237

1

754.237

52.941

.001

Within Groups

2792.354

196

14.247

 

 

Total

3546.591

197

 

 

 

 

The mean and SD score of paid group at Baseline (First Assessment) are M=8.88 S.D.= 5.480; and non paid group are M=9.41 S.D.= 4.845 (Table-4) F(1,198)=.525, p=.470; Partial η2 = .003}(Table-5). In Second Assessment the mean and SD score of paid group M=4.01 S.D.=3.842 and non paid group are M=7.33 S.D.= 4.662 (Table-4)F(1,197)=30.143, p=.001; Partial η2 = .133}(Table-5). In Third Assessment the mean and SD score of paid group M=1.79 S.D.=2.587 and non paid group are M=6.83 S.D.= 4.971(Table-4) F(1,197)=80.650, p=.001; Partial η2 = .290}(Table-5). In Fourth Assessment the mean and SD score of paid group M=1.78 S.D.=3.064; and non paid group are M=6.04 S.D.=4.951(Table-4) F(1,196)=53.256, p=.001; Partial η2 = .214}(Table-5). and In Fifth Assessment the mean and SD score of paid group are M=1.78 S.D.=2.485 and non paid group are M=5.68 S.D.=4.742 (Table-4) F(1,196)=52.941, p=.001; Partial η2 = .213}(Table-5).

The above scores indicate no significant group differences in SAPS scores of baseline and statistically significant differences in subsequent assessments. (Table-4) The experimental group scored significantly lower than the control group (Table-5).

Discussion

The objective of the study was to explore if paid work assignment has any contribution in reducing psychopathology of hospitalized chronic schizophrenic patients. The results indicate that paid work significantly contributed in reducing both positive and negative symptoms of experimental subjects.There are a few studies that investigated the effects of remuneration on clinical and psychosocial status of chronic schizophrenic patients. The results of the present study are in agreement with the findings of earlier studies.

Kumar20 studied the impact of vocational rehabilitation on psychopathology in in-patients with chronic schizophrenia through PANSS. He found significantly lowered positive and negative syndrome in experimental group compared to control group. The experimental group was engaged in vocational activities and paid monetary incentive for the same. The control group was neither engaged in any rehabilitation activities nor received any payments. In this paradigm, it was not possible to ascertain whether the improvement in psychopathology was just due to participation in work or payment or a combination of two. The present study took care of it and engaged the control group in the same activities in which experimental group was engaged. This permitted isolation of the differential effects of remuneration. The results revealed superior outcomes for the paid group. Ajimol21 from Bangalore noted a higher degree of overall functioning and reduced symptoms in rehabilitated patients compared to those not vocationally rehabilitated.

In a study 150 patients with schizophrenia or Schizo-affective Disorder to Pay or No-Pay condition and placed them in jobs. 22 The effects of pay conditions on psychopathology were assessed through PANSS. To assess changes in level of symptom severity from intake to follow up, mean scores were calculated for the PANSS Total Scores and the five component scores for subjects in pay and no-pay condition. Analysis of Covariance (ANCOVA) was used to partial out the effects of baseline scores. The results revealed that Pay subjects showed significantly lower symptom scores. Danial18 also reported that vocational rehabilitation significantly improved negative symptoms and in quality of life. Psychopathological indicators proved to be the best predictors of work performance both cross-sectionally as well as in the long term course7and found negative symptoms but not positive symptoms to be associated with unemployment in schizophrenia.12,3 Recent studies on person related factors on vocation al outcome suggest that severity of symptoms rank below work performance when measured concurrently but it has significant role in vocational outcome. Payment as such having reinforcing capacity can be used in various employment programmes to reduce psychopathology and enhance the output of patients.

Conclusion

The results of the present study clearly indicate that paid work assignment results in reduction in both positive symptoms and negative symptoms in hospitalized chronic schizophrenic patients. It implicates the significant contribution of work participation of the patients not only for the purposes of vocational rehabilitation but also for gains in psychopathology. A model of remuneration based involvement of the patients is being contemplated by this work. The study adopted a quasi-experimental approach. The model remains to be tested through randomized controlled trials for demonstration of its efficacy in symptom improvement and changes in work related behaviors.

Acknowledgement This paper is part of the ICMR sponsored ad hoc project No. 5/4-4/14/M/2006-NCD-1 titled “Effects of the Remunerative Jobs on Psychopathology and Psychosocial Functioning of Hospitalized Chronic Schizophrenic Patients”

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