Rehab Rounds: Training Persons With Schizophrenia in Illness Self-Management: A Randomized Controlled Trial in Japan

Abstract

Despite the worldwide shift from inpatient to community-based treatment for individuals with severe mental illness, Japanese psychiatric services remain hospital based. In 1998, Japan had 29 psychiatric beds per 10,000 persons, twice as many as in most European countries and five times as many as in the United States (1). The reasons for Japan's slow transition to a community-based mental health system are both economic and cultural. For instance, 90 percent of psychiatric beds are in private for-profit hospitals. There is little incentive for inpatient facilities to discharge patients promptly, because the Japanese health care system provides universal coverage with virtually unlimited reimbursement for inpatient services, and the government does not have a mechanism for financing the relocation of resources from hospitals to communities (2). In addition, the stigma associated with mental illness in Japanese families is high (3). Thus a patient's primary residence is the psychiatric hospital, and opportunities are provided for periodic visits from the family.However, psychiatric rehabilitation principles and practices are beginning to take root in Japan. Anzai and his colleagues at the Matsuzawa Psychiatric Hospital in Tokyo have adapted an empirically validated skills training program to prepare patients with schizophrenia for life in the community after discharge from the hospital. In this column, they report the results of a randomized controlled trial of this approach in an inpatient facility serving a large urban center.

Skill Building: Assessing the Evidence

“…They cited six RCTs indicating that findings in support of the effectiveness of daily living skills training combined with social skills training were "strong" (15,(33)(34)(35)(36)(37). Of these, three RCTs examined the effects of the Social and Independent Living Skills Program and found the practice to be effective in improving independent living skills (33)(34)(35).…”

“…They cited six RCTs indicating that findings in support of the effectiveness of daily living skills training combined with social skills training were "strong" (15,(33)(34)(35)(36)(37). Of these, three RCTs examined the effects of the Social and Independent Living Skills Program and found the practice to be effective in improving independent living skills (33)(34)(35). The three remaining RCTs (15,36,37) of Functional Adaptation Skills Training with older adult patients and with Latino participants who had chronic psychosis were implemented by Patterson (a developer of the program) and colleagues (37).…”

“…For example, the most recent Cochrane review (10) cited high risk of reporting bias and lack of reported protocols in two studies by Patterson and colleagues (15,37), as well as high risk of attrition bias in one of these studies (37). Four of the six studies cited by Arbesman and Logsdon (33)(34)(35)(36) were not included in the 2012 Cochrane review, although the reasons for their exclusion are not clear because these studies were not cited in the Cochrane review's summary of excluded studies. Despite the conflicting findings of these reviews, the positive results of studies cited by Arbesman and Logsdon indicate that additional welldesigned research using specific protocols for improving life skills is warranted.…”

“…Some studies have included substantial numbers of participants with different ethnic and racial backgrounds in their study samples (49), including a number of studies with participants who were predominantly African American (50,51). Examples of other cross-cultural studies include an RCT of illness self-management conducted with hospitalized individuals with schizophrenia in Japan (33) and an RCT of successful skill-building interventions conducted in a Chinese psychiatric hospital (52). To our knowledge, no studies have reported using race or ethnicity as an independent variable for determining the relative effectiveness of skill-building approaches for people with serious behavioral health problems.…”

Support management in schizophrenia: a systematic review of current literature

“…Moreover, several studies and mounting evidence has suggested that the CRM is an effective method for the rehabilitation of patients suffering from schizophrenia. [88][89][90][91][92] For example, the results obtained by Xiang et al revealed that CRM was an effective and feasible psychosocial intervention for Chinese patients with schizophrenia. 93 Specifically, the results indicated a significant improvement in social functioning, insight, and psychiatric symptoms in the CRM group as compared to the control group receiving only psychoeducation.…”