| Background:Schizophrenia is a kind of severe mental disease which is characterized by long term of illness duration, hard to recover, incomplete in cognition, and especially high rate of aggression, which is unstable for society and family. Most of the patients take anti-psychotic medication after they received inpatient treatment and return back to community. However, due to the poor adherence to medication, patients with schizophrenia may suffer from severe symptom, poor social functioning, and commit to aggressive behaviors.“Community-integrated social skills training” was introduced into China in the 20 th century as a rehabilitation intervention program for patients with schizophrenia. It is effective in helping patients with schizophrenia to improve their medication adherence, mental symptom, social functioning and insight. However, this kind of intervention program is mainly used for inpatients with schizophrenia, and no articles have been found for the effects on community patients. In addition, because the “community-integrated social skills training” is mainly based on listening to the lecture statically which cannot draw patients’ attention and improve their memory as well, this kind of intervention is only effective in a short term. Learning video knowledge passively could not help patients to make use of them in their routine life. Therefor patients failed to recognize their improvement in their heath and symptom which are achieved by “community-integrated social skills training”, and were poor in their quality of life in domains of psychology, physiology, society and environment. It’s necessary for us to search for an effective intervention therapy for the rehabilitation of patientswith schizophrenia.This study explored the feasibility and effect of “community-integrated social skills training” on community patients with schizophrenia. And then, we combined medication treatment, “community-integrated social skills training” and Tai-chi(Chinese traditional aerobic exercise) together(hereinafter known as modified “community-integrated social skills training”), conducted it on community patients with schizophrenia, and finally assessed its short-term and long-term effect on medication compliance, clinical symptom, rehabilitation situation, social functioning, quality of life and aggression of patients with schizophrenia.Objective:To investigate the short-term and long-term effect of modified “community-integrated social skills training” on patients with schizophrenia, and provide suggestion on the rehabilitation of community patients with schizophrenia.Material and Methods: There are 3 parts for the article. Part I: We collected demographic data and clinical data of documented patients with schizophrenia from Fengtai District in Beijing from June,2009 to June,2013. This research is a cross-section study. Chi-test, univariate and multivariate logistic regression analysis were used to investigate the five-year tendency of aggression and aggression-associated factors. Part II: A randomized controlled trial was applied and 208 patients with schizophrenia from community were assigned randomly to medication treatment combined with “community-integrated social skills training” group(hereinafter known as rehabilitation group): 102 cases, and medication treatment only group(hereinafter known as control group): 106 cases. 6 Months “community-integrated social skills training” was conducted. Medication treatment combined with “community-integrated social skills training” was applied to rehabilitation group and pure medication treatment was applied to control group. Clinical symptom related indexes, rehabilitation related indexes, treatment related indexes, and social relationship related index(for example quality of life) were adopted to evaluate the intervention effects. Generalized Linear Mixed Models(GLMMs)were used to evaluate group effects, time effects, and group× time interaction effects. Chi-test or t-test were used to evaluate group or time differences on clinical indexes including PANSS, social functioning and aggression.Part III:A randomized controlled trial was applied and 244 patients with schizophrenia from community were assigned randomly to medication treatment combined with modified “community-integrated social skills training” group(hereinafter known as rehabilitation group): 118 cases, and medication treatment only group(hereinafter known as control group): 126 cases. 12 Months modified“community-integrated social skills training”(ie “community-integrated social skills training” plus Tai-chi) was conducted. Medication treatment combined with modified“community-integrated social skills training” were applied to rehabilitation group and pure medication treatment was applied to control group. Generalized Linear Mixed Models(GLMMs)were used to evaluate group effects, time effects, and group × time interaction effects. Chi-test or t-test were used to evaluate group or time differences on clinical indexes including PANSS and quality of life.Results:1.The rate of case with aggressive behavior increased significantly from 2009 to 2013 in Fengtai District of Beijing(÷2=4.589,P=0.032). Variables including living without spouse(P<0.001, OR=11.0(5.86-20.50)) and higher scores of positive symptom(P<0.001, OR=1.12(1.09-1.15)) were associated with increased risk of aggression, And adherence to medication(P<0.001,OR=0.41(0.29-0.59)), living with parental family(P=0.008, OR=0.54(0.34-0.85),and older age(P=0.057,OR=0.98(0.97-1.00)) were associated with reduced risk of aggression. Suffering from physical diseases was found to be an important risk factor which might promote patients to commit more than one type of aggression(P=0.039, OR=1.74(1.03-2.95)). 2. Through 6 months’ “community-integrated social skills training”, and compared with control group, the rehabilitation group had lower scores of negative symptoms(18.,18±1.27 vs 18.47±1.41,F=3.461, P=0.038), a greater improvement in social functioning(12.22±2.76 vs 13.11±2.49,F=15.794, P<0.001) and insight(14.50±1.68 vs 14.31±2.80,F=2.214,P=0.014), decreased auto-aggression rate(0.00% vs 3.96%, χ2=3.961, P=0.047), and higher medication compliance rate(97.96% vs 88.12%, χ2=-7.388, P=0.025) other than the following variables which were not significantly different from control group: relapse rate(1.02% vs 2.97%, χ2=0.960, P=0.327), physiological domain of quality of life(20.39±4.68 vs 19.74±4.88, F=0.332,P=0.574), psychological domain of quality of life(17.42±2.90 vs 17.56±3.38, F=1.671,P=0.198), social domain of quality of life(8.45±2.03 vs 8.09±2.18, F=2.552,P=0.108) and environmental domain of quality of life(22.21±5.56 vs 21.13±4.89, F=0.090,P=0.779). Compared with 3 months’ assessment results, the rehabilitation group showed a higher medication compliance rate(97.96% vs 79.41%, χ2=-16.906, P<0.001), lower aggression rate(14.29% vs 25.49%, χ2=3.922, P=0.048) and lower verbal aggression rate(8.16% vs 17.65%, χ2=3.975, P=0.046) other than relapse rate(1.02% vs 1.96%, χ2=0.299, P=0.584) which was not significantly different after 6 months’ intervention. 3. Through 12 months’ modified “community-integrated social skills training”, and compared with control group, the rehabilitation group had lower scores of PANSS total score(44.39 ± 2.90 vs 45.00 ± 2.60, F=15.733, P<0.001), negative symptoms(17.60±1.20 vs 18.40±1.50, F=18.391, P<0.001), a greater improvement in psychological domain of quality of life(2.35±3.10 vs 1.79±2.80, t=1.450, P =0.030) and social domain of quality of life(0.65±1.20 vs 0.04±3.20, t=2.038, P =0.043), decreased relapse rate(0.88% vs5.83%, χ2=4.349, P=0.037), aggression rate(5.26% vs 25.83%, χ2=18.583, P<0.001), verbal aggression rate(3.51% vs 15.00%, χ2=9.063, P=0.003), and auto-aggression rate(0.00% vs 4.17%, χ2=4.854, P=0.028), and increased medication compliance rate(91.23% vs 65.83%, χ2=25.538, P<0.001) other than the following variables which were not significantly different from control group: positive symptom(4.90±1.40 vs 5.00±1.40, F=1.436,P=0.239), general psychopathology symptom(21.80±2.00 vs 21.60±1.80, F=1.068,P=0.327), rate of property aggression(0.88% vs 2.50%, χ2=0.916, P=0.338), and rate of aggression against others(0.88% vs 3.33%, χ2=1.687, P=0.194). Compared with 6 months’ assessment results, the rehabilitation group showed a higher medication compliance rate(91.23% vs 79.66%, χ2=7.408, P=0.025), lower aggression rate(5.26% vs 15.25%, χ2=6.241, P=0.012) and lower verbal aggression rate(3.51% vs 10.17%, χ2=4.006, P=0.045) other than rate of property aggression(0.88% vs 3.38%, χ2=1.736, P=0.188) and rate of aggression against others(0.88% vs 0.85%, χ2=0.001, P=0.980) which was not significantly different after 12 months’ intervention.Conclusion:1. This study confirmed that demographic factor, treatment-related factor and clinical symptoms were associated with aggression for patients with schizophrenia in Fengtai Districts of Beijing. As the controllable risk factor of aggression, none-adherence to medication has attracted more and more attention from the society. Effective rehabilitation therapies are necessary for the improvement of medication adherence such that aggression rate shall be decreased among patients with schizophrenia. 2. Compared with control group, patients with schizophrenia who were subjected to the “community-integrated social skills training” intervention is effective in lowering the rate of aggressive behavior especially verbal aggression and auto-aggression, improving score of negative symptom score, insight and social functioning by means of increasing patients’ medication adherence. 3. The modified “community-integrated social skills training” was applied for the purpose of achieving better effect. It is not only effective in helping community schizophrenia patients to improve negative symptom and reduce aggression rate but also in improving their quality of life and decreasing the relapse rate. Therefor, the modified “community-integrated social skills training” shall be regarded as an effective intervention therapy for the rehabilitation of community patients with schizophrenia. |
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