Running head: THE IMPACT OF OCCUPATION-BASED INTERVENTIONS

The Impact of Occupational-Based Interventions on Activity and Participation in Clients

with Schizophrenia: A Systematic Review

By

Brianna Teigen

B.A. Allied Health Sciences, The College of St. Scholastica, 2013

Erica Leighty

B.A. Allied Health Sciences, The College of St. Scholastica, 2013

A Graduate Research Project Submitted In Partial Fulfillment of the Requirements

For the Degree of Master of Science in Occupational Therapy

Department of Occupational Therapy

The College of St. Scholastica

Duluth, MN.

May 2014

Graduate Research Project Faculty Advisor: Steven Cope, Sc.D., OT/L

I, the undersigned, approve the final copy of the manuscript:

__________________________________________ ____5-29-2014___________

Faculty advisor date

____________________________________________ ____5-29-2014___________

Diane Holliday-Welsh, Second reader date

 UMI Number: 1585277

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THE IMPACT OF OCCUPATION- BASED INTERVENTIONS ii

Abstract

The object of this systematic literature review was to determine the effects of occupation-
based interventions on activity limitations and participation performance for adults with
schizophrenia. This review was compiled from reviewing six quantitative studies, all of
which were randomized controlled trials. Two independent reviewers searched and
screened databases to locate and select articles based on set inclusion and exclusion
criteria. Each article was reviewed independently, and discussed together, with a third
party available to resolve any differences of opinions. Two of the five studies reviewed
showed that occupation-based treatment had statistically significant improvements
compared a control group’s treatment. Two studies did not find a significant difference
between the performance of control and experimental groups. One study showed the
control group was more effective than the experimental group. The results of this review
have determined that there are mixed findings that suggest high variation in what
occupation-based treatment consists of for clients with schizophrenia. Further research is
needed to gain a better understanding of effective occupation-based treatment
interventions for adults with schizophrenia.

Key words: schizophrenia, occupation-based interventions, activity limitations,

participation performance, adults
THE IMPACT OF OCCUPATION- BASED INTERVENTIONS iii

Table of Contents

Page

Abstract ii

Table of Contents iii

Introduction 1

Background 1

Literature Review 4

Method 6

Results 7

Discussion 11

Conclusion 14

References 15

Appendix 18
THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 1

Introduction

Schizophrenia is a severe, chronic mental illness that affects over 3 million

Americans and 24 million people worldwide (“Schizophrenia,” 2013). Experts believe

that schizophrenia is caused by a combination of factors such as genetics, the

environment, brain chemistry, and brain structure (“What is Schizophrenia?,” 2013).

There are several interventions that mental health professionals, including occupational

therapists, use when treating clients who have schizophrenia, but the best form of

treatment has not yet been established. More research is needed to establish a basis of

successful occupational therapy interventions for clients with schizophrenia.

Background

Schizophrenia is a “chronic, severe, and disabling brain disorder” in which those

affected may hear voices and believe people are reading their minds (“What is

Schizophrenia?,” 2013). It is difficult to identify specific traits found in all people with

schizophrenia because there is much disagreement about the defining features of this

disorder (Brown & Stoffel, 2011). According to the Diagnostic and Statistical Manual of

Mental Disorders, for an individual to be diagnosed with schizophrenia they must exhibit

two of the following symptoms for at least one month: delusions, hallucinations,

disorganized speech, disorganized or catatonic behavior, or negative symptoms (Brown

& Stoffel, 2011). Schizophrenia is a complex disorder that has both positive and negative

symptoms. The positive symptoms “represent aberrations in behavior or behavior that is

not typically present in other individuals, such as hallucinations, delusions, disorganized

thinking and disorganized behavior” (Brown & Stoffel, 2011, p.179). Negative

symptoms are “the absence of typical function, such as flat affect, social withdrawal, and
THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 2

difficulty initiating activity” (Brown & Stoffel, 2011, p.179). People with schizophrenia

are typically unable to sort through all of the sensory stimuli in their environment and

may have enhanced perceptions of colors, sounds, and sights (Brown & Stoffel, 2011).

Schizophrenia is most prevalent in the age group of 15-35 year-olds and is currently

affecting about seven percent of the adult population (“Schizophrenia,” 2013).

Schizophrenia impacts each person differently, but some common limitations include:

grooming, dressing, and other self-care skills, care for others, home management, and

communication. Those living with schizophrenia have more difficulty completing

complex tasks, such as instrumental activities of daily living (IADL) compared to basic

activities of daily living (ADL) (Lipskaya, Jarus, & Kotler, 2010).

Mental health and mental illness are terms commonly used and recognized by

healthcare providers as they are becoming more prevalent in our modern society. Mental

health is defined as “health conditions that are characterized by an alteration in thinking,

mood, or behavior (or some combination thereof) associated with distress and/or

impaired functioning” (Mental Heath Basics, 4/21/13). Mental illness is estimated as a

growing cause of disability, according to the World Health Organization, and it is

predicted to become the leading cause of disability, especially depression (Mental Health,

9/8/13).

Treatments for schizophrenia aim to eliminate the symptoms of the disease.

Typically this is accomplished by using a combination of: pharmacology, which uses

antipsychotic medications; psychology, such as psychotherapy; life management skills,

work skills, and home management skills; as well as rehabilitation services of physical

therapy, occupational therapy, and speech therapy (“What is Schizophrenia?,” 2013).

THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 3

There is clear evidence that biological treatments are the most effective when they are

combined with psychosocial interventions, environmental and social therapies, or life

skills training. Family psychoeducation works with the family and a counselor to provide

information about mental illness and teach interaction skills that reduce stress within the

family (Bonder, 2010). Occupational therapists may work with a wide range of severities

and types of schizophrenia and their associated symptoms, therefore multiple treatment

options are utilized. The occupational therapist’s role is to determine the best

intervention based on a client’s occupational profile and desired functional goals.

Evaluating and discussing a client’s current activities and their limitations, as well as the

client’s view of their own participation and restrictions are important aspects of the

treatment process. According to the International Classification of Functioning (ICF),

activity is defined as “execution of a task or action by an individual.” An individual

having difficulties executing those activities demonstrates activity limitations. The ICF

defines participation as involvement in a life situation; restrictions occur when an

individual experiences difficulties with involvement in life situations (The ICF: An

overview, 10/23/13). Interventions do not typically target schizophrenia, but rather are

intended for treating serious mental illnesses. All treatment options, such as skills

training, supported employment, and education on environmental modifications has the

goal of enhancing occupational performance (Brown & Stoffel, 2011).

THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 4

Literature Review

A search of electronic databases was completed to evaluate available literature on

schizophrenia and interventions done by occupational therapists. A search using the

terms “schizophrenia” and “occupational therapy” revealed approximately 150 articles

that were filtered to identify specific articles to meet the criteria of this systematic review.

The majority of the current literature relating to occupational therapy and schizophrenia

includes background information, rather than experimental or quantitative studies

showing effects of interventions. Much of these articles are based on case studies,

observations, or qualitative studies or reviews. Additionally, studies of occupational

therapy interventions commonly involve a co-intervention with other healthcare

professionals.

A majority of the articles found in the search of electronic databases discuss

cognition and role performance for those diagnosed with schizophrenia. Cognitive

impairments shown in schizophrenia may be similar to those demonstrated with a

neurological disorder. It is stated by Falk-Kessler and Bear-Lehm that “these problems

may require similar kinds of therapeutic attention” (2008, p. 62). Occupational therapy

practice involving mental health clients has been focusing on role performance with an

emphasis on social skills and interpersonal skills. When working in a specific practice

area, it is common to focus on the client’s body structure and functional impairments; it is

best if the foci are combined to treat the whole client, not just the disorder (Falk-Kessler

& Bear-Lehm, 2008). A review of several articles found a “deprivation” in the ability to

complete occupations that create meaningful life experiences for those with

schizophrenia (Urlic & Lentin, 2010).

THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 5

A review of literature from early 1990 until late 2008 showed several studies

exploring occupations of people with schizophrenia but these studies revealed no

interventions used specifically by occupational therapists. The studies were completed

through the use of diaries, experience samples, and qualitative methods. This shows a

gap in the literature of studies that are being done experimentally and quantitatively.

Cognition, motor functioning, and hand functioning were mentioned in several articles,

but the impact on role performance, daily occupations, and vocational performance were

not discussed.

There are several studies that have experimentally investigated the effects of

occupation-based or activity-based interventions. A search of electronic databases found

between five and ten articles that were systematically reviewed. Of the articles found,

five of them are randomized controlled trials (Cook, Chambers & Coleman, 2009;

Buchain, Vizzotto, Neto, & Elkis, 2003; Hoshii et al., 2013; Liberman, Wallace,

Blackwell, Kopelowicz, Vaccaro, Mintz, 1998; Tatsumi, Yotsumoto, Nakamae, &

Hashimoto, 2011) and one is a quasi-experimental design (Katz & Keren, 2011).

After reviewing the current and available literature, there is no evidence of a

systematic review dedicated to examining the effectiveness of occupational therapy

interventions on the activity limitations and participation restrictions for clients with

schizophrenia. Based on this information, the purpose of this review is to systematically

examine the effectiveness of occupational therapy interventions on the activity limitations

and participation restrictions in adults with schizophrenia. Evidence appraised and

summarized for this systematic review will help guide occupational therapists when

determining the best intervention for their clients who have schizophrenia.
THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 6

The research question for this systematic literature review will be: What are the

effects of an occupation-based intervention on activity and participation outcomes in

adult clients with schizophrenia?

Method
Search Strategies

In order to acquire articles, the databases that were searched include PubMed,

Medline, CINAHL, and ProQuest. Reference lists from literature gathered were also

searched for potential articles. The following key terms were used: (Schizophrenia OR

Schizo-affective disorder OR Schizophren*) AND (Occupational therapy OR

Occupational therapy interventions) AND (Interventions OR occupation-based

interventions OR Activities of Daily Living OR Activity based intervention OR activities

and participation). Using the inclusion and exclusion criteria, both authors independently

reviewed the full-text documents. An additional independent reviewer was available to

discuss areas of difference. Each reviewer completed hand searching of journals to locate

additional studies that are relevant to this systematic review.

Inclusion and Exclusion Criteria

A preliminary search of existing systematic reviews revealed there were no

reviews of direct relevance to this research question. The articles included in the review

had the following characteristics: studies with occupation-based interventions that are

thoughtfully and therapeutically designed to meet the goals of the client, such as daily

living skills and social skills training, and/or crafts; studies with outcomes that address

activity and participation dimensions of the ICF definitions; studies with levels one

through five on the American Occupational Therapy Association (AOTA) Evidence

THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 7

Hierarchy (Trombly, Tickle-Degnen, Baker, Murphy, & Ma, 1999) (See Table 1); studies

that have been published within the last 15 years; studies with participants in the adult

population with a diagnosis of schizophrenia. The exclusion criteria included: studies

with interventions that do not include activity-based or occupation-based intervention or

interventions that use only pharmacology, surgery, or psychotherapy.

Procedure

The interventions were analyzed in terms of their quality and effectiveness

according to criteria developed for the “AOTA Evidence-Based Practice Project”

(Lieberman & Sheer, 2002). This methodology was chosen because of the emphasis the

AOTA is placing on evidence-based practice. AOTA has determined that this will be the

methodology for evidence-based practice and recommends using an approach consistent

with the occupational therapy profession. The “AOTA Evidence-Based Practice Project”

criterion categorizes research articles into specific levels of evidence (I-V) according to

research design, sample size (A= n>20 per condition; B= n<20 per condition), and

internal and external validity. A summary of findings from each article has been

compiled into an evidence-based table (See Table 2). The internal validity of each article

was determined by using the Internal Validity Form produced by Concordia University

Wisconsin (See Table 3).

Results

Study Characteristics

There were 11 articles considered for this systematic review. Five of the articles

were excluded (see Table 4), resulting in a total of six articles that were included. All of
THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 8

the critically appraised articles were Level I studies. Five articles were randomized

controlled trials and one was a randomized quasi-experimental study design. Internal

validity ratings were based on a scale from 1-12 with 1- 4 being weak, 5-9 being

moderate, and 10-12 being strong. Critical appraisal showed that five articles had

moderate internal validity (Buchain, et al., 2003; Cook, Chambers, Coleman, et al., 2009;

Hoshii, et al., 2013; Liberman, et al., 1998; Tatsumi, et al., 2012) and one was rated as

strong internal validity rating (Katz & Keren, 2011). Common threats to internal validity

included evaluator and investigator bias.

There was high variability across the six studies in terms of the interventions.

These approaches include: subject chosen activities, occupational therapist chosen

activities, occupational therapy added into their daily regimen of treatment,

pharmacology, pharmacology plus occupational therapy, ADL retraining, neurocognitive

rehabilitation, teaching activity specific routines, cooking activities, psychosocial

occupational therapy, and social skills training.

There were both similarities and differences in the interventions between all

articles in duration and intensity. Three of the six articles had a duration of six months

(Buchain, et al., 2003; Hoshii, et al., 2013; Liberman, et al., 1998), one study had the

duration of 12 months (Cook, et al., 2009), one for the duration of 15 weeks (Tatsumi, et

al., 2012) and one for the duration of six to eight weeks (Katz & Keren, 2011). The

intensity among the articles varied from one hour per week for 15 weeks to 12 hours per

week for six months. The intervention groups in each study varied between two to three

groups with various numbers of participants in each. However, each study included an

occupational therapy only group or occupational therapy plus another intervention and a
THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 9

control group. All of the participants had a diagnosis of schizophrenia although one

study included other psychotic diagnoses such as bipolar disorder, among several others.

Each diagnosis was documented individually giving the reader the ability to single out

the diagnosis of schizophrenia. The treatment settings were similar, having occupational

therapy taking place in either an inpatient hospital setting or a community-based

rehabilitation setting. Overall, there were a combined total of 269 participants with an

average age of 41.9 years old. There was a heterogeneous mix of gender, progression of

their psychotic disorder, age of onset, and length of hospitalization.

The outcomes measured varied with no two studies using the same outcome

measures to evaluate activity limitations and participation performance. The outcome

measures relative to activity limitations and participation performance include: Global

Assessment of Functioning (GAF), Social Functioning Scale (SFS), Scale of Interactive

Observation in Occupational Therapy (EOITO) which is derived from the Scale for

Interactive Observation of Psychiatric Inpatients and adapted for occupational therapy,

Routine Task Inventory- Expanded (RTI-E), Activity Card Sort (ACS), Reintegration to

Normal Living Index (RNL), Rehabilitation Evaluation Hall and Baker Scale (REHAB),

and the Social Activity Scale (SAS).

Effects of Occupation-based Practice

Two of the five studies showed that occupation-based treatment interventions

were more effective than the control group’s treatment (Buchain, et al., 2003; Katz &

Keren, 2011). In each of these studies, the beneficial effect of the occupation-based

treatment was statistically significant; the effect was also viewed as clinically significant
THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 10

for Buchain, et al. (2003), but not Katz and Keren (2011) where the mean difference

between control and experimental groups was a rank of 7.92. In the case of these two

studies, the control groups that did not show clinical importance were an activity training

approach and medication only approach. Two of the five studies did not show a

significant difference between the occupation-based experimental group and the control

group (Cook, et al., 2009; Tatsumi, et al., 2012). Both the experimental and control

groups improved equally as a result of treatment. One of the five studies showed that the

control group’s treatment, which was a skills training group, was more effective than the

occupation-based treatment group, although the difference was not statistically significant

(Liberman, et al., 1998).

Hoshii, et al. (2013) compared two occupation-based interventions rather than an

experimental group (occupation-based intervention) and a control group. Instead, this

study compared the effects of the client choosing the activity versus the therapist

choosing the activity as its intervention; both conditions were considered occupation-

based. Results of this study showed that the client-chosen group had better engagement

and performance, although not statistically significant, in therapy outcomes than the

therapist-chosen group.

Two studies (Katz & Keren, 2011; Liberman, et al., 1998) attempted to measure

long-term effects; one at six months post intervention and one at two years post

intervention. One of these long-term effects showed no statistically significant change

from end of treatment to follow-up (Katz & Keren, 2011). The other showed

improvement compared to the end of treatment but it did not achieve statistical

significance at follow-up (Liberman, et al., 1998).

THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 11

The authors of each study did not report any negative effects. Authors did not

discuss the costs for conducting the studies or the overall benefits to the experimenters,

participants, and readers.

Discussion

Main Findings

There are two main findings that have emerged from this systematic literature

review. The first of these findings was that the majority of studies suggested that

occupation-based treatment did not outperform other modes of treatment when working

with adults who have schizophrenia. In one study, the occupation-based treatment group

performed worse than the control group (Liberman, et al., 1998) and in two studies the

occupation-based treatment group performed as well as, but no better than the control

group (Cook, et al., 2009; Tatsumi, et al., 2012). Conversely, the findings from two

studies (Katz & Keren, 2011; Buchain, et al. 2003) showed that there was a benefit of

occupation-based intervention for adults with schizophrenia. These occupation-based

interventions outperformed the instruction of activity specific routines and the use of only

antipsychotic medication, with no intervention. The mixed findings could be explained

by the varying intervention approaches, treatment times, and an unclear definition of

interventions. There was not a consistent pattern of treatment times (number of sessions

and duration of treatment) that showed a relation to the results being statically significant.

None of the studies reviewed provided details of the interventions, which does not allow

an explanation for why only two studies were effective.

THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 12

Another explanation of why there was variability in findings could be due to the

definition of occupation-based intervention. The definition for occupation-based

intervention formulated for this study was based on researcher’s knowledge and other

resources, as there was no clear definition in the literature. This definition may have

hindered the quantity of articles that were included in this review. In addition to the

researcher’s definition not matching that of the authors’, there was a difference in what

occupational therapy intervention meant to each author.

The second main finding was the lack of evidence seen in the literature on this

topic. The number of total studies available on this topic, six, represented a low volume

of evidence on an important area of occupational therapy practice. Interestingly, all of

the studies reviewed were from strong designs (randomized controlled trials); however,

there were not any case studies, single-subject designs, or one-group pre-post studies

done on activity limitations and participation performance for clients with schizophrenia.

Strengths and Limitations

This study was limited by a lack of generalizability to populations other than

adults with schizophrenia, as the articles were only pertinent to this population of

individuals. A second limitation was that articles were only considered if activity

limitation and participation restriction outcome measures met the definitions of the ICF;

the body functions and structures were not considered. In addition, positive and negative

symptoms of schizophrenia were not explored. Lastly, there were time restrictions that

impacted this review causing researchers to potentially overlook studies related to this

topic, including studies that have not yet been published.

THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 13

A strength of this study was the author’s access to a vast array of resources such

as databases and experienced clinicians and researchers.

Suggestions for the future

Based on the identified gaps in the literature, more case studies and single-subject

designs would be important because these study designs are intended to show whether the

intervention is effective before comparing it to another form of treatment and progressing

towards higher levels of rigor in research. However, there were several case studies

about living with schizophrenia, but nothing directly relating the diagnosis to their daily

occupations. At this point, research should not be comparing interventions, as there is

little evidence that occupation-based interventions are effective for adults with

schizophrenia. There should also be a standardized definition for occupation-based

interventions to provide a common framework for practitioners and researchers. Future

researchers should state what the occupational therapy intervention protocol for their

study is, and be specific about the interventions for the control group to allow replication

of future studies.

Clinical Implications

The clinical implication for this study is that occupation-based treatments may

benefit some adult clients with schizophrenia in ADL performance and social functioning

skills. However, because this review revealed conflicting findings from a small number

of studies, clinicians should proceed cautiously if using occupation-based interventions

for adults with schizophrenia. Practitioners would benefit from more research, as it
THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 14

would help determine if occupation-based treatment activities and interventions are

effective for improving activity and participation outcomes for adults with schizophrenia.

Conclusion

This study has investigated the effectiveness of occupation-based interventions

for adults with schizophrenia. The main findings from this study suggest there is mixed

and inconclusive evidence on the effectiveness of occupation-based interventions for

adults with schizophrenia. In two studies, occupation-based treatment did not outperform

other modes of treatment, while two others provided evidence that client’s activity and

participation maybe improved. The small number of studies available on this topic

reveals a lack of evidence and suggests the need for future research.
THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 15

Reference

Bonder, B. R. (2010). Psychopathology and function, (4th ed.). Thorofare, NJ:

Slack Incorporated.

Brown, C., & Stoffel, V.C. (2011). Occupational therapy in mental health: A

vision for participation. Philadelphia, PA: F.A. Davis Company.

Buchain, P. C., Vizzotto, A., Henna Neto, J. & Elkis, H. (2003). Randomized controlled

trial of occupational therapy in patients with treatment-resistant schizophrenia.

Revista Brasileria, De Psiquiatria, 25(1), 26-30. doi: 10.1590/S1516-

44462003000100006

Cook, S., Chambers, E., & Coleman, J. H. (2009). Occupational therapy for people with

psychotic conditions in community settings: A pilot randomized controlled trial.

Clinical Rehabilitation, 23(1), 40-52. doi:10.1177/0269215508098898

Cope, S., & Mollinger, L. (2011). Concordia University Wisconsin Internal Validity

Rating Form: Unpublished Manuscript. Concordia University Wisconsin.

Falk-Kessler, J., & Bear-Lehm, J. (2008). Hand function in persons with chronic mental

illness. Occupational Therapy in Mental Health, 19(1), 61-67. doi:

10.1300/J004v19n01

Hoshii, J., Yotsumoto, K., Tatsumi, E., Tanka, C., Mori, T., & Hashimoto, T. (2013).

Subject-chosen activities in occupational therapy for the improvement of

psychiatric symptoms of inpatients with chronic schizophrenia: A controlled trial.

Clinical Rehabilitation, 27(7), 638-645. doi: 10.1177/0269215512473136

THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 16

Katz, N., & Keren, N. (2011). Effectiveness of occupational goal intervention for clients

with schizophrenia. American Journal of Occupational Therapy, 65(3), 287-296.

doi: 10.5014/ajot.2011.0011347

Liberman, R. P., Wallace, C.J., Blackwell, G., Kopelowicz, A., Vaccaro, J. V., & Mintz,

J. (1998). Skills training versus psychosocial occupational therapy for person with

persistent schizophrenia. The American Journal of Psychiatry, 155(8), 1087-1091.

Lieberman, D. & Scheer, J. (2002). AOTA’s evidence-based literature review

project: An overview. American Journal of Occupational Therapy, 56(3), 344-

359.

Lipskaya, L., Jarus, T., & Kotler, M. (2011). Influence of cognition and symptoms of

schizophrenia on IADL performance. Scandinavian Journal of Occupational

Therapy, 18(3), 180-187. doi: 10.3109/11038128.2010.490879

Mental Health Basics. (2011). Center for Disease Control. Retrieved April 21, 2013,

from http://www.cdc.gov/mentalhealth/basics.htm

Mental Health. (2013). The American Occupational Therapy Associated Inc. Retrieved

September 8, 2013 from http://www.aota.org/en/Practice/Mental-Health.aspx

Schizophrenia. (2013). Retrieved from

www.who.int/mental_health/management/schizophrenia/en/

Tatsumi, E., Yotosumoto, K., Nakamae, T., & Hashimoto, T. (2012). Effects of

occupational therapy on hospitalized chronic schizophrenia patients with severe

negative symptoms. The Kobe Journal of Medical Sciences, 57(4), E145-E154.

The ICF: An overview. (n.d.) Retrieved October 23, 2013 from

http://www.cdc.gov/nchs/data/icd9/ICFoverview_FINALforWHO10Sept.pdf
THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 17

Trombly, C. A., Tickle-Degnen, L., Baker, N., Murphy, S., & Ma, H. (1999). Levels of

evidence for occupational therapy outcomes research. Unpublished table, Boston

University.

Urlic, K., & Lentin, P. (2010). Exploration of the occupations of people with

schizophrenia. Australian Occupational Therapy Journal, 57, 310-317. doi:

10.1111/j.1440-1630.2010.00849x

What is schizophrenia? (2013, April). Retrieved from

http://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml
THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 18

Appendix

Table 1: Levels of Evidence and Classification Scheme – Quantitative Literature

Grade for Definition

Design

I Randomized controlled trials (RCT’s) using experimental designs

with randomization to groups and repeated measure designs with
randomization to sequence of treatments. Also includes meta-
analysis that analyzes RCT’s.

II Non-RCT-2 group, two group (treatments) comparisons, repeated

measures but with two conditions. Also includes meta-analysis that
analyzes non-RCT studies.

III Non-RCT-1 group, one group pre and post.

Cohort, case control, cross-sectional designs.

IV Single-subject design.

V Narratives, case studies, qualitative designs, expert opinion.

Grade for Definition

Sample Size

A n > 20 per condition

B N < 20 per condition

Grade for Definition

Internal
Validity

1 High internal validity: no alternate explanation for outcomes.

2 Moderate internal validity: attempt to control for lack of

randomization.

3 Low internal validity: two or more serious alternative explanations

for outcome

Grade for Definition

External
Validity

a High external validity: S’s represent population – AND – treatments

represent current practice.
THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 19

b Moderate external validity: between high and low

c Low external validity: heterogeneous sample without being able to

understand whether effects were similar for all diagnosis – OR –
treatment does not represent current practice.
Note. Adapted from the original table developed by Trombly, Tickle-Degnen, Baker,
Murphy, & Ma (1999); used with the permission of Linda Tickle-Degnen
THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 20

Table 2: Evidence Table

Author/ Level/Design/ Intervention and

Year Study Objectives Participants Outcome Measures Results Study Limitations

Hoshii, Compare Level I - RCT Patients received six SCG had better The small number of
Yotsumoto, therapeutic effects 59 patients with months of OT for 2 treatment outcomes participants at one
Tatsumi, T of subject-chosen schizophrenia hours once a week. and overall higher hospital limited study.
anka, activities and 30 in the SCG, 29 in SCG: completed The engagement in Authors suggest the
Mori, therapist-chosen the TCG. COPM to determine activities than the intervention time
Hashimoto activities in OT activities. Subjects TCG. period may have been
2013 for inpatients with SCG- mean age: 57.1 determined a set of too short to be
schizophrenia. activities they would effective.
TCG- mean age: 55.9 wish to complete.
TCG: no COPM,
therapist chose
activities based on
treatment
recommendations.
When a patient
completed an activity,
the next activity was
chosen following the
same pattern as the
first activity.

To investigate the Level I- RCT Patients received 12 Neither group’s SFS A limitation to this
effectiveness of months of OT. scores improved study was that it did
OT for people 44 participants with Participants in both significantly after the not target the
THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 21

with psychotic psychotic disorders, the OTG and the TAU 12 months of participant’s cognitive
conditions and to 30 in the OTG, 14 in group were both given treatment. function. It was also
Cook, inform future the TAU. the SFS at baseline, 6 limited to a particular
Chamber, research designs. months, 9 months and local population with
Coleman, 12 months. unspecified ethnicity
2009 Mean age- 39 years which makes
old. generalizing this study
restricted.

To investigate if Level I: RCT Two groups were From baseline to Small sample size and
OT is effective compared, the EG Month 6, the EG the number of
Buchain, when added to a 26 participants total. received group improved with a withdrawals from the
Vizzotto, psychopharmacol 12 in the CG and 14 in psychopharmacologic Magnitude of the study.
Neto, Elkis, ogical treatment in the EG. al treatment (with effect (d) = -1.22
2013 treatment clozapine) plus meaning it is of a
Diagnosis:
resistance sessions of OT. The large clinical
schizophrenia
schizophrenia. CG received only importance and a
CG- mean age: 36.6 clozapine. The EOITO significance (p)= 0.02
was given to statistically
EG- mean age: 33.7 participants 7 times significant. The CG’s
throughout the study. EIOTO scores
improved from
baseline to 6 months
but were not
statistically
significant.
THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 22

Katz & The Level I Participants had a The IADL section of Small sample size
Keren effectiveness of Quasi- total of 18 the RTI showed and large dropout
2011 OGI in clients experimental, individual significant differences rate of those who
with pre/post test treatment sessions met the inclusion
from baseline to end
schizophrenia over 6-8 weeks. criteria. Person
was compared 18 total participants Pretest was given, of treatment for the who administered
to FEP and an 6 - OGI as well as a post- OGI group. The ACS assessments wasn’t
ATA (CG). 6 - FEP treatment test and a had significant completely blinded
6 – ATA 6-month follow-up differences from to treatment effects.
test. baseline to end of There may have
Diagnosis: Outcome measures: been significant
treatment for the OGI
schizophrenia or RTI, ACS, and improvements had
and ATA groups.
schizoaffective RNL. the treatment time
However, there was been longer.
disorder
no significant change
Mean age: 30 in any measures from
the time of ending
treatment to 6-month
follow-up.

Tatsumi, To determine Level 1: RCT Patients in the OTG The total Rehab score General of this
Yotsumoto, whether OT did cooking did not significantly study was limited
Nakame, can improve 38 participants activities while change from baseline because the inter-
Hashimoto, the were divided into patients in the CG group comparisons
to post intervention
(2011) interpersonal either the OTG did not. The showed no
relationships (EG) or the CG. patients were for either intervention significant
and negative n=19 in EG and evaluated twice: group. difference. Another
symptoms of n=19 in the CG. once before the limitation was the
hospitalized Diagnosis: intervention and small sample size.
chronic schizophrenia once after the
THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 23

schizophrenia completion of the

patients with EG mean age: 57.6 15 sessions of OT.
severe negative CG mean age: 57.7 Participants were
symptoms. evaluated using the
BPRS, SANS,
Rehab and the
POMS.
Liberman, To compare the Level 1: RCT Participants were For the SAS, there The case managers
Wallace, community randomly assigned was no significant were not blind to
Blackwell, functioning of 84 participants to either participate effect in favor of the the psychosocial
Kopelowic outpatients divided into a CG in the psychosocial treatment
skills training group.
z, Vaccaro, with persistent (psychosocial occupational conditions.
Mintz, forms of occupational therapy group or The skills training
(1998) schizophrenia therapy) and a the skills training group showed
after treatment SSTG. group. These statistically greater
with groups met 12 improvement over the
psychosocial Diagnosis: hours weekly for 6 two year follow up
OT of social Schizophrenia months with 18 than those in the OTG.
skills training. Mean age: 37.1 months of follow
up by a case-
manager in the
community.
Participants were
given the ILSS,
GAS, BPRS, and
SAS.
Note. This table is a product of AOTA’s Evidence-Based Practice Project and the American Journal of Occupational Therapy.
Copyright © 2012 by the American Occupational Therapy Association. May be freely reproduced for personal use in clinical or
educational settings as long as the source is cited. All other uses require written permission from the American Occupational Therapy
Association. To apply, visit www.copyright.com.
THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 24

Lieberman, D. & Scheer, J. (2002). AOTA’s evidence-based literature review project: An overview. American Journal of
Occupational Therapy, 56(3), 344-359.

RCT = Randomized Control Trial; SCG = Subject Chosen Group; TCG = Therapist Chosen Group; COPM = Canadian Occupational
Performance Measure; EG = Experimental Group; CG = Control Group; OGI = Occupational Goal Intervention; FEP = Frontal
Executive Program; ATA = Activity Training Approach; RTI = Routine Task Inventory; ACS = Activity Card Sort; RNL =
Reintegration to Normal Living Index; BRPS = Brief Psychiatric Rating Scale; SANS = Scale for Negative Symptoms; Rehab =
Rehabilitation Evaluation Hall and Baker; POMS = Profile of Mood States; SSTG = Social Skills Training Group; ILSS =
Independent Living Skills Survey; GAS = Global Assessment Scale; SAS = Social Activities Scale; OTG = Occupational Therapy
Group; TAU = Treatment as usual; EIOTO = Scale of Interaction Observation in Occupational Therapy; OT = Occupational Therapy
THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 25

Table 3: Interval Validity Form

Bias relates INTERNAL VALIDITY RATING FORM YES NO

to:

Participants 1. Sample selection: did investigators clearly specify inclusion/exclusion criteria to minimize sample heterogeneity? In
studies with a control group, this bias should affect both groups equally.
Participants 2. Attrition (participant drop out): is participant drop out less than 20% in total sample and balanced between groups? If
drop out is greater than 20% and unbalanced between groups, attrition may be a concern. Consider reasons for attrition if
reported by researchers.
Participants 3. Attentional bias (Hawthorne effect): was participant behavior unaltered by experimenter expectations or attention? This
bias should affect both groups equally assuming the control or placebo group gets equal attention.
Participants 4. Baseline equality: Were groups equal on important participant characteristics (e.g. age, gender, severity of disability) and
outcome measures (dependent variables) at study outset? If not, were differences dealt with appropriately in data analysis?
Participants 5. Maturation or spontaneous recovery: there is no evidence that patients got better because of maturing (children) or
natural healing (adults in acute phase of recovery) between pre and post testing? Not a significant concern in studies where
data collection is completed in a short time (single session) or if there is a control group.
Outcome 6. Psychometrics of dependent variables: Were the outcome measures valid and reliable for measuring the outcomes of
Measures interest? In studies with a control group, this bias should affect both groups equally.
Outcome 7. Instrumentation bias: were the investigators careful to record information accurately and with calibrated instruments? In
Measures studies with a control group, this bias should affect both groups equally.
Outcome 8. Blinding: Evaluator bias: was the outcome assessor unaware of group assignment (treatment or control)? Investigator
Measures bias: If possible, was the person providing the intervention blinded to group assignment?
Outcome 9. Testing effects: the outcomes of interest were measured such that learning or fatigue were not likely to account for
Measures changes? Did investigators take care to measure at the same time of day at pre and post-testing? For studies where all
THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 26

participants experience multiple conditions, was the order of the conditions randomized (counterbalanced)? If order effects
are not relevant based on the research design, ok to say “yes”. In studies with a control group, this bias should affect both
groups equally.
Research 10. Data Analysis: Was the correct statistical analysis used for the data?
Methods
Research 11. Was there adherence to the intervention? Did investigators keep track of and report compliance to treatment? In studies
Methods with a control group, this bias should affect both groups equally.
Research 12. Co-intervention: participants did not begin or stop an activity/treatment in addition to their assigned intervention.
Methods Participants assigned to control group did not begin treatment of interest (contamination). In studies with a control group,
this bias should affect both groups equally.
Total

Note. Cope, S., & Mollinger, L. (2011). Concordia University Wisconsin Internal Validity Rating Form: Unpublished
Manuscript. Concordia University Wisconsin.
THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 27

Table 4: Excluded Articles

Reference Reason for

Exclusion

Bejerholm, U. (2010). Relationships between occupational engagement and status of and satisfaction with There was no
sociodemographic factors in a group of people with schizophrenia. Scandinavian Journal of Occupational Therapy, intervention used
16, 244-254. doi: 10.3109/11038120903254232 and was qualitative
study.

Foruzandeh, N., & Parvin, N. (2013). Occupational therapy for inpatients with chronic schizophrenia: A pilot randomized Results only
control trial. Japan Journal of Nursing Science, 10, 136-141. doi: 10.1111/j.1742-7924.2012.00211.x measured positive
and negative
symptoms, not
activity and
participation.

Katz, N., Fleming, J., Keren, N., Lightbody, S., & Maeir, A. H. (2002). Unawareness and/or denial of disability: Study was all case
Implications for occupational therapy intervention. Canadian Journal of Occupational Therapy, 69, 281-292. studies and surveys,
no experimental
study completed.

Lipskaya, L., Jarus, T., & Kotler, M. (2011). Influence of cognition and symptoms of schizophrenia on IADL performance. Study was a
Scandinavian Journal of Occupational Therapy, 18, 180-187. doi: 10.3109/11038128.2010.490879 paper/pencil survey
with no
THE IMPACT OF OCCUPATION- BASED INTERVENTIONS 28

intervention
measuring activity
and participation.

Morimoto, T., Matsuyama, K., Takeda, S. I., Murakami, R., & Ikeda, N. (2012). Influence of self-efficacy on the There was no
interpersonal behavior of schizophrenia patients undergoing rehabilitation in psychiatric day-care services. treatment, only
Psychiatry and Clinical Neurosciences, 66, 203-209. doi: 10.1111/j.1440-1819.2012.02332.x evaluations of
cognition, mental
stability, and
interpersonal skills
and behavior.