A prospective cohort study of community functioning among psychiatric outpatients

Psychiatry Research 259 (2018) 125–134

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A prospective cohort study of community functioning among psychiatric outpatients

MARK

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Alan H.L. Chana, , Samuel Y.S. Wonga, Wai-Tong Chienb a b

The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong School of Nursing, The Hong Kong Polytechnic University, Hong Kong

A R T I C L E I N F O

A B S T R A C T

Keywords: Human occupation Volition Environment Expressed emotion Stigma Chinese

The present study analyzed the community functioning among Chinese people with common mental disorders and their relationships with different factors under the framework of Model of Human Occupation. The research team followed up a stratified random sample of 238 patients in three public psychiatric specialist outpatient clinics in Hong Kong in one year. The patients completed assessments at baseline and 12-month follow-up in four areas of community functioning (i.e., self-care, independent living skills, social skills, and work skills), selfesteem, self-efficacy, physical functioning, behavioral regulation, mental states, family expressed emotion, and perceived social stigma. The data showed that after 12 months, the patients had positive changes in self-care, work skills, and behavioral regulation. Those patients who had higher levels of self-esteem at baseline and reduced their negative reactions to stigma were more likely to improve social skills, while those patients who perceived less discrimination at baseline and enhanced their self-esteem would have a higher likelihood of making improvement in work skills. The findings implied that the rehabilitation services for people with common mental disorders might target on the enhancement of self-esteem and reduction of discrimination experience to facilitate their improvement in social skills and work skills.

1. Introduction Increasing number of psychiatric patients are receiving treatments in the community (Hospital Authority, 2011). Apart from pharmacological treatment, psychiatric patients have a variety of rehabilitation needs such as relapse prevention, stress management, and community living skills training (Chien and Norman, 2003; Wong et al., 2011). Since Chinese patients commonly put a strong emphasis on improvement in functioning through rehabilitation (Tse et al., 2012), the present study was designed to analyze the multiple factors that could affect the different areas of community functioning among a cohort of Chinese psychiatric patients. The assessment of community functioning can be based on the behavioral capacity of a person in coping with the demands in different domains of occupations such as self-care and work (Bellack et al., 2007). This study utilized the Model of Human Occupation (MOHO) as the guiding framework for the analyses (Kielhofner, 2008). The model was used because the theoretical constructs can integrate the findings from previous research on how patients are motivated to adapt to the task demands in different occupations and how personal and environmental factors may affect different domains of functioning. For

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example, the previous studies have shown that self-esteem and self-efficacy, which are parts of the volition component in MOHO (Kielhofner, 2008), could predict the levels of social functioning among patients with severe mental illness (Davis et al., 2012; Pratt et al., 2005). In particular, those patients with higher levels of self-efficacy might be more motivated to apply work-related skills in their workplaces (Cardenas et al., 2013). Those patients who participated in self-esteem enhancement program might have greater improvements in functionally related outcomes (Borras et al., 2009; Hall and Tarrier, 2003). In addition, studies have shown that the participation in social and workrelated activities among patients can be affected by their physical functioning (Dixon et al., 2001), communication skills (Lexén and Bejerholm, 2015), neurocognitive functioning, and mental states (Gupta et al., 2012; Prouteau et al., 2005). All of these factors are parts of the performance capacity component of MOHO that directly relates to their adaptations to the demands of social and work-related activities (Kielhofner, 2008). Apart from the factors at the individual levels, MOHO has a concrete description of how individual's motivation, behavioral pattern, and functional performance may vary in different environmental contexts (Kielhofner, 2008). As such, the environment component of the model may integrate the previous research findings of

Corresponding author. E-mail address: [email protected] (A.H.L. Chan).

http://dx.doi.org/10.1016/j.psychres.2017.10.019 Received 19 February 2017; Received in revised form 5 August 2017; Accepted 7 October 2017 Available online 10 October 2017 0165-1781/ © 2017 Elsevier B.V. All rights reserved.

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concerning the directions of associations are specified in Fig. 1.

a negative relationship between high levels of family expressed emotion (EE) and poor functional outcomes of patients with severe mental illness (Hooley, 2007; Kim and Miklowitz, 2004). It was because the perceived stress from critical and hostile family members (constructs of EE) in the family environment might intensify the perceptions of disabilities among patients and prevent them from seeking independence in self-care, social, and work-related activities (Inoue et al., 1997; Schlosser et al., 2010). On the other hand, the social stigma of mental illness, especially those perceived by patients (Chien et al., 2014), may represent another major barrier to their participation in many community activities in the social environment, as described in MOHO (Kielhofner, 2008). This is consistent with the findings from the previous studies which showed that the perceived social stigma of mental illness might prevent people with mental illness from building interpersonal relationships and seeking employment (Cechnicki et al., 2011; Henry and Lucca, 2004; Tsang et al., 2003). Since there is a paucity of longitudinal research on community functioning among psychiatric patients in the Chinese population, this study was designed to follow up a representative sample of Chinese psychiatric outpatients and assess their changes in community functioning after one year. The main objective of this study was to identify the factors that may facilitate them to make improvements in different areas of community functioning (i.e., self-care, independent living skills, social skills, and work skills). Based on the findings from the previous research and the framework of MOHO (Kielhofner, 2008), the present study hypothesized that the longitudinal changes and improvements in different areas of community functioning were associated with the baseline scores or longitudinal changes of study variables related to the volition (e.g., self-esteem, self-efficacy), performance capacity (e.g., physical functioning, behavioral regulation, mental states), and environment contexts (e.g., family expressed emotion, perceived social stigma) of patients. The specific hypotheses

2. Methods 2.1. Study design The present study utilized a 12-month, prospective cohort study design to evaluate the impact of different factors on community functioning among a cohort of psychiatric outpatients who received medical and rehabilitation services in the community. The design of a 12-month follow-up was based on the previous findings of a positive change in different areas of community functioning among psychiatric patients after one year (Kikuchi et al., 2013; Kukla et al., 2012; Saravanan et al., 2010; Walters et al., 2011). 2.2. Study sites The study was conducted at two public psychiatric specialist outpatient clinics (SOPC) located in the New Territories East cluster and one public psychiatric SOPC located in the Kowloon Central cluster under the management of the Hospital Authority. The Hospital Authority is the statutory body that manages all public hospitals in Hong Kong. It is the major provider of mental health care to an estimated population of about 70,000–200,000 people with mental disorders in the local territory (Hospital Authority, 2011). In 2010–2011, the Hospital Authority provided a total of 739,186 psychiatric out-patient attendances to the service users (Hospital Authority, 2012). In this study, the researchers invited the clinical staff in the three SOPCs to assist in the recruitment of research participants based on their collaborative network. The number of psychiatric out-patient attendance in the three SOPCs (121,321) was equivalent to 16% of the total number in the local territory in 2010–2011 (Hospital Authority, 2012). Fig. 1. Schematic representation of the study hypotheses about the relationships between community functioning and study variables. T0: Baseline. T1: 12-month follow up. Solid lines and dotted lines indicate positive and negative associations, respectively.

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2.4.3. Self-efficacy The Chinese General Self-Efficacy (GSE) scale (Zhang and Schwarzer, 1995) was used to assess the perceived self-efficacy of patients in coping with demands in everyday life. The instrument has good content validity and internal consistency among Chinese patients with schizophrenia (Chiu and Tsang, 2004).

2.3. Participants The present study employed a secondary data analysis from a past research project in 2010–2012 with consent from the principal investigator (third author). The available data (n = 238) fully satisfied the required sample sizes for various statistical analyses employed in this study based on power and sample size analyses (available online in Supplementary Materials). The demographic and clinical information of patients were retrieved from the clinic records of patients. The inclusion criteria for participants were: (a) Hong Kong Chinese residents, (b) Cantonese/Mandarin speaking, (c) aged 18–65, (d) primarily diagnosed by psychiatrists as having “schizophrenia and other psychotic disorders” (e.g., schizoaffective disorder, delusional disorder), “mood disorders” (e.g., major depressive disorder, bipolar disorder), and “anxiety disorders” (e.g., generalized anxiety disorder, obsessive-compulsive disorder), according to the criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (American Psychiatric Association, 2000). The above diagnostic categories were chosen because they represented the largest groups of service users in psychiatric SOPCs in Hong Kong (Hospital Authority, 2011). The study excluded those patients who had a duration of mental illness for more than ten years because they might be less responsive to psychiatric rehabilitation (Bowie et al., 2010; Wiersma et al., 1998). The study also excluded those patients who were mentally unstable (as suggested by the on-site clinical staff) and those who had cognitive impairments, intellectual disabilities, or physical disabilities.

2.4.4. Physical functioning The “physical functioning” subscale of SLOF scale (Schneider and Struening, 1983) was used to assess the basic physical functioning of patients, including vision, hearing, speech, and mobility of upper and lower limbs. 2.4.5. Behavioral regulation The “social acceptability” subscale of the original English version of SLOF scale (Schneider and Struening, 1983) was used to assess the behavioral regulation of patients. The subscale contains such items as the frequency of physically/verballing abusing others, destroying property, crying/clinging, and taking property from others without permission. The items were taken to indicate the impulsivity control and self-regulatory behavior of patients. 2.4.6. Mental states The original English version of Brief Psychiatric Rating Scale (BPRS) was used to assess the mental states of patients (Overall and Gorham, 1962). Four factors were identified from exploratory factor analysis, namely, affective symptoms, negative symptoms, positive symptoms, and suspiciousness/hostility (see Table S1 in online Supplementary Materials). The extracted factors were largely consistent with the metaanalytic study (Shafer, 2005).

2.4. Assessments The patients in the cohort study completed assessments at baseline (T0) and 12-month follow-up (T1). The primary outcomes included four areas of community functioning, namely, self-care, independent living skills, social skills, and work skills. The secondary outcomes included self-esteem, self-efficacy, physical functioning, behavioral regulation, mental states, family expressed emotion, and perceived social stigma of patients.

2.4.7. Family expressed emotion (EE) The family member's interaction styles with patients were assessed using the Chinese version of Level of Expressed Emotion (LEE) scale (Chien and Chan, 2009). The instrument contains four subscales that measure different dimensions of family expressed emotion as perceived by patients. Two subscales measure the levels of emotional over-involvement and intrusiveness of family members in daily interaction with patients, while two subscales evaluate the levels of acceptance and support given by family members. The content validity and psychometric properties of Chinese LEE scale have been validated in patients with severe mental illness (Chien and Chan, 2009). The present study utilized the self-report measure of expressed emotion because it had a relative advantage of simple administration that was more suitable for use in the routine clinical settings as compared to the traditional assessment methods based on family interview and complex coding of the interview data (Chien and Chan, 2009).

2.4.1. Community functioning Four subscales of the original English version of Specific Levels of Functioning (SLOF) scale (Schneider and Struening, 1983) were used to assess the self-care, independent living skills, social skills, and work skills among the patients. The SLOF scale has been reviewed to be an ecologically valid measure of patient functioning in the community (Harvey et al., 2011). For this study, the self-care performance of patients was assessed with the “personal care skills” subscale, such as personal hygiene, grooming, and taking care of own possession and living space. The independent living skills of patients were assessed with the “activities” subscale, including shopping, using transportation, and handling personal finance. The social skills of patients were assessed with the “interpersonal relationship” subscale, including their abilities to make effective communication, initiating contacts with others, and forming/ maintaining friendships. The work skills of patients were assessed with the “work skills” subscale, such as being able to work with minimal supervision, sustain work efforts, and follow verbal instructions accurately.

2.4.8. Perceived social stigma The impact of perceived social stigma on patient functioning was assessed using the modified version of Perceived Devaluation and Discrimination (PDD) scale (Wright et al., 2000). The scale has two dimensions. One dimension assesses the “discrimination experience” of patients in daily living, such as losing opportunities to find jobs or obtain certain permits and licenses. Another dimension assesses the amount of “reaction to stigma” displayed by patients, as indicated by their withdrawal behaviors in society and intention to maintain secrecy about their mental illness. The original scale was translated into Chinese and reviewed by an expert panel. From exploratory factor analysis, the above two factors were identified, which were identical to the factor structure of the original scale (see Table S2 in online Supplementary materials).

2.4.2. Self-esteem The Chinese Rosenberg Self-Esteem (RSE) scale (Zhang and Norvilitis, 2002) was used to evaluate the feelings of self-worth or selfdeprecation of patients. The instrument has adequate content validity and internal consistency among patients with different chronic illness (Martin et al., 2006; Zhang and Leung, 2002).

2.5. Procedures Ethical approval for data collection was obtained from the research 127

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skills, social skills and work skills in the SLOF scale (Schneider and Struening, 1983). This criterion was consistent with the use of a 10point difference (out of 100) to classify different levels of patient functioning in the Global Assessment of Functioning scale (Hall, 1995) and the method used in a previous study (Eisen et al., 2007). For testing our study hypotheses, multiple regression models and binary logistic regression models were used to identify those significant predictors of changes (T1 minus T0 scores) and “improvement” (as defined above) in each area of community functioning, respectively. Two groups of predictors, as indicated by the baseline scores or the change scores of the secondary outcome variables, were entered separately into the regression models to reveal their temporal or parallel relationships with changes or improvements in community functioning, respectively. To avoid deletion of important confounders in multivariate analyses, the potential predictors that attained a level of significance of 0.10 in univariate analyses were entered into the regression models. As informed by the previous research (Chien et al., 2014; Gupta et al., 2012; Harvey, 2011; Heslin et al., 2016; Lee et al., 2015; Prouteau et al., 2005), the multivariate analysis controlled the effects of age, gender, education, duration of illness, diagnosis, participation in rehabilitation services, and the baseline score of each area of community functioning. All of the above statistical analyses were conducted with two-sided tests at the significance level of 0.05, using IBM SPSS Statistics 20.

Table 1 Demographic and clinical characteristics of study participants. Variable

Cohort sample (n = 238)

Mean age (SD) Gender Male Female Education Primary or below Secondary Tertiary Psychiatric diagnosis Schizophrenia and other psychotic disorders Mood disorders Anxiety disorders Mean duration of mental illness in years (SD) Participated in following rehabilitation services in the study period Home visits by case managers Medication management Psychoeducation Social skills training Family therapy Other treatments Any one of the above rehabilitation services

43.03 (11.79) 68 (28.6) 170 (71.4) 36 (15.1) 148 (62.2) 54 (22.7) 66 (27.7) 161 (67.6) 11 (4.6) 3.30 (2.04)

76 (31.9) 142 (59.7) 128 (53.8) 33 (13.9) 31 (13.0) 46 (19.3) 199 (83.6)

Note. Values are numbers and percentages (in parentheses) unless stated otherwise.

3. Results ethics committees of the affiliated university of the principal investigator and the collaborating hospitals from 2010 to 2012. During the recruitment period, the research team had invited 500 patients to participate in this study after stratified random sampling by using a sampling fraction of 10%. By using the computer-generated random numbers, the participants were randomly selected from a target list of eligible participants whose names were listed in an alphabetical order and provided by the research collaborator at each study site. The response rate in each study site ranged from 60% to 71%. After obtaining the written consent of the participating patients, an initial assessment was conducted individually with each patient by a trained assessor at each study site. The assessor approached them for reassessments at the study site after 12 months. Each patient spent about 30–45 min to complete the assessments. Before data collection, a nurse educator in mental health nursing (principal investigator) provided three-day training to the two assessors (employed as research assistants) for using the psychometric instruments. The two assessors followed a standardized protocol written in Chinese (developed by the research team) to conduct face-to-face interviews with the patients and their family caregivers for assessing patient functioning and mental states. After the interview, the patients were asked to complete the other assessment measures (RSE, GSE, LEE, and PDD scales) in a set of standardized questionnaires printed in written Chinese. The assessors completed the ratings in the English version of SLOF scale (Schneider and Struening, 1983) and BPRS (Overall and Gorham, 1962) based on the information provided by the patients and their caregivers. The assessors then discussed the ratings with the case managers (nurses or occupational therapists) or attending psychiatrists of the patients at the study sites. The ratings were finalized after the case managers or attending psychiatrists agreed on the ratings.

3.1. Sample characteristics Table 1 summarizes the characteristics of 238 patients who remained in the cohort study from an original sample of 332 patients. Among them, 27.7% were diagnosed with schizophrenia and other psychotic disorders, 67.6% were diagnosed with mood disorders, and 4.6% were diagnosed with anxiety disorders. Most of them (83.6%) had participated in psychiatric rehabilitation services in the past year. The characteristics of dropout participants are summarized in Table S3 in the online Supplementary materials. 3.2. Changes in primary and secondary outcomes The descriptive statistics for all primary and secondary outcomes at baseline (T0) and 12-month follow-up (T1) are summarized in Table 2. The distribution of change scores (T1 minus T0 scores) and the percentages of patients with a positive or negative change in each outcome are presented in Table S4 in the online Supplementary Materials. The effect sizes of significant differences were evaluated by Cohen's d and r for paired t-tests and Wilcoxon signed-rank tests, respectively. The data showed that after one year, the patients had significant positive changes in self-care (r = 0.13, p = 0.006) and work skills domains (r = 0.24, p < 0.001), while a non-significant trend of positive change in social skills was also indicated (r = 0.09, p = 0.053). In contrast, change in independent living skills was insignificant (p = 0.870). Apart from community functioning, they had a significant positive change in behavioral regulation (r = 0.14, p = 0.002) after one year. However, the data also indicated a significant overall decrease in physical functioning (r = 0.14, p = 0.002) and self-efficacy (Cohen's d = 0.16, p = 0.007). In addition, the patients had significant increase in negative symptoms (r = 0.27, p < 0.001), suspiciousness/hostility (r = 0.28, p < 0.001), and perceived intrusiveness of their family members (Cohen's d = 0.13, p = 0.020). The effect sizes of differences reported above were in the small to medium range (Cohen, 1988).

2.6. Statistical analysis The demographic and clinical characteristics of patients were summarized by descriptive statistics. For examining changes, paired ttests were used for normally distributed data, while Wilcoxon signed rank tests were used for non-normally-distributed data. This study operationally defined clinical improvements in each area of community functioning as having positive change equivalent to 10% of the total score in the relevant subscale that assesses self-care, independent living

3.3. Checking for data distribution and selection of subgroups for multivariate analyses After checking of data, we found that the distribution of the 128

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Table 2 Descriptive statistics and across-time differences of all outcome measures (n = 238). Variable (Possible score range) Community functioning Self-care (7–35)b Independent living skills (11–55)b Social skills (7–35)b Work skills (6–30)b Physical functioning (5–25)b Behavioral regulation (7–35)b Mental states Positive symptoms (0–36)b Negative symptoms (0–30)b Affective symptoms (0–30)b Suspiciousness/hostility (0–12)b Self-esteem (10–40)c Self-efficacy (10–40)c Family environment Emotional over-involvement (13–52)c Intrusiveness (13–52)c Acceptance (13–52)c Supportive attitude (13–52)c Perceived social stigma Discrimination experience (7–35)c Reaction to stigma (9–45)c

Baseline (T0 score)

12-month follow-up (T1 score)

Z/ t(237)a

p

35 55 31 24 25 33

35 55 32 29 25 34

2.74 − 0.16 1.94 5.13 − 3.11 3.12

0.006* 0.870 0.053 < 0.001** 0.002** 0.002**

(33.95, 35) (47, 55) (11, 35) (11, 30) (22, 25) (28, 35)

(35, 35) (48.95, 55) (14, 35) (12, 30) (20, 25) (27.95, 35)

0 (0, 10) 0 (0, 7) 10 (0, 23) 0 (0, 3) 26.04 (4.16) 22.80 (7.86)

1 (0, 13.05) 3 (0, 12) 9 (0, 25.05) 0 (0, 9) 26.24 (4.55) 21.63 (6.82)

1.16 5.95 − 0.17 6.14 0.84 − 2.74

0.246 < 0.001** 0.868 < 0.001** 0.402 0.007*

23.62 24.57 41.31 44.11

24.06 25.53 41.11 43.69

(8.05) (7.69) (7.03) (7.36)

1.20 2.34 − 0.51 − 1.08

0.231 0.020* 0.609 0.283

17.75 (4.25) 30.45 (5.51)

0.31 − 0.75

0.755 0.455

(7.88) (7.36) (7.24) (6.93)

17.64 (3.98) 30.71 (4.91)

Note. The no. of patients who met the criterion of clinical improvement in self-care, independent living skills, social skills, and work skills domains was 8 (3.4%), 12 (5.0%), 64 (26.9%), and 88 (37.0%), respectively. a A positive and negative sign denotes increased and decreased score at 12-month follow-up (T1) with reference to baseline (T0), respectively. b Values are medians and weighted average at the 5th and 95th percentile (in parentheses). c Values are means and SDs (in parentheses). * p < 0.05. ** p < 0.003 (with adjustments for no. of comparisons).

variables “change in self-care” and “change in independent living skills” were heavily skewed, and only a limited number of patients met the criterion of clinical improvements in these two areas (n = 8 and 12, respectively). Therefore, we did not perform regression models on these two dependent variables. On the other hand, we excluded those patients who scored more than 90% in the social skills and work skills domains at T0 from logistic regression analyses. It was because those patients with such a high score would not meet the criterion of clinical improvement at T1 according to the study's definitions (i.e., positive score change equivalent to 10% of the total score of the social skills or work skills subscale). After the subgroup selection, it resulted in 120 and 146 patients available for computing the logistic regression models for predicting improvements in social skills and work skills, respectively. Moreover, because the present study recruited a heterogeneous sample of patients with different diagnosis, we examined the possible group differences between different diagnostic groups in the dependent variables/outcomes in each regression model. Since there was no indication of a significant group difference, we proceeded to report the findings in the whole study sample in each regression model.

skills (adjusted OR = 0.87, 95% C.I. = [0.78, 0.97], p = 0.011). 3.5. Longitudinal predictors of changes and improvements in social and work skills The two multiple linear regression models are summarized in Table 5. The results showed that change in social skills was positively associated with change in physical functioning (β = 0.17, p = 0.005) and negatively associated with change in negative symptoms (β = − 0.18, p = 0.006), while change in work skills was positively associated with change in self-efficacy (β = 0.20, p = 0.001). The two logistic regression models are shown in Table 6. The results showed that improvement in social skills could be predicted by reduction of positive symptoms (adjusted OR = 0.90, 95% C.I. = [0.81, 1.00], p = 0.048) and negative reactions to stigma (adjusted OR = 0.92, 95% C.I. = [0.85, 0.99], p = 0.036), while improvement in work skills could be positively predicted by change in self-esteem (adjusted OR = 1.13, 95% C.I. = [1.00, 1.28], p = 0.048). 4. Discussion

3.4. Baseline predictors of changes and improvements in social and work skills

The current study investigated the factors that could predict changes and improvements in different areas of community functioning among a cohort of psychiatric outpatients under the framework of MOHO (Kielhofner, 2008). The data showed that after one year, the patients had positive changes in some major areas of community functioning such as self-care and work skills, but some negative and unexpected findings, such as an increased level of negative symptoms and a decreased level of physical functioning, were also indicated. The multivariate analyses showed that the patients with higher levels of self-esteem at baseline had a higher likelihood of achieving clinical improvements in social skills, while discrimination experience in the social environment would undermine their positive changes and improvements in work skills. Besides, it was indicated that change in social skills might associate positively with change in physical functioning

The multiple linear regression models for “change in social skills” and “change in work skills” are shown in Table 3. None of the baseline predictors identified in bivariate analyses were significantly associated with change in social skills, but discrimination experience in T0 significantly and negatively predicted change in work skills (β = − 0.13, p = 0.040). The multiple logistic regression models (Table 4) showed that patients with higher levels of self-esteem at T0 were more likely to make improvement in social skills (adjusted OR = 1.15, 95% C.I. = [1.01, 1.30], p = 0.030). Those who experienced less discrimination in their social environment were more likely to make improvements in work 129

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Table 3 Multiple linear regression for exploring the baseline predictors of change in social skills and work skills. Bivariate analysisa

Multiple linear regressionb

Dependent variable

Independent variable

r

p

B (95% CI)

β

p

Change in social skills

Negative symptoms (T0) Family's intrusiveness (T0) Negative symptoms (T0) Self-esteem (T0) Self-efficacy (T0) Family's intrusiveness (T0) Discrimination experience (T0)

0.20 − 0.11 0.11 − 0.15 − 0.18 − 0.15 − 0.12

0.002* 0.088 0.083 0.017* 0.006* 0.021* 0.063

1.76 (− 0.40, 3.92) − 0.08 (− 0.20, 0.03) 0.00 (− 2.05, 1.92) − 0.10 (− 0.32, 0.12) − 0.03 (− 0.15, 0.08) − 0.08 (− 0.19, 0.02) − 0.21 (− 0.40, − 0.01)

0.10 − 0.09 0.00 − 0.07 − 0.04 − 0.10 − 0.13

0.109 0.151 0.948 0.386 0.558 0.124 0.040*

Change in work skills

Note. The multivariate analysis controlled the effects of age, gender, education, duration of illness, diagnosis, participation in rehabilitation services, and the baseline score of social skills/work skills. a Spearman's correlation coefficients were used to test the associations between each independent variable and dependent variable. b Models summary: Adjusted R2 = 0.23 and 0.22 for the regression models predicting change in social skills and work skills, respectively. * p < 0.05.

and hostility towards people/environment (Bottoms et al., 2015; Krakowski and Czobor, 2012). Besides, their increased level of negative symptoms might be associated with their decreased level of physical functioning or participation in physical activities (Vancampfort et al., 2012), which in turn intensify their levels of psychomotor retardation and emotional withdrawal. On the other hand, the data indicated that the patients might have a decreased level of self-efficacy and an increased level of perceived intrusiveness of family members. Since the effect sizes were small and they were not statistically significant after adjustment for multiple comparisons, we did not seek for further explanation in this study.

and negatively with change in negative symptoms, while change in work skills might associate positively with change in self-efficacy. The subgroup analyses further indicated that the patients with improvements in social skills tended to have better control of positive symptoms and reductions in negative reactions to stigma, while those patients with improvement in work skills were more likely to have improvement in self-esteem. The implications of the study findings are summarized as follows. 4.1. The possible explanations for the positive and negative outcomes The data from this cohort study indicated that the patients had positive changes in self-care, social skills, work skills, and behavioral regulation after one year. The patients might benefit from the psychosocial intervention (e.g., psychoeducation, social skills training, home visits by case managers) that commonly target on these functional areas during the study period. Moreover, the regression analyses showed that their improvements in social skills and work skills might associate with a higher level of self-esteem and a lower level of discrimination experience at baseline, respectively. However, there were some negative outcomes of patients after one year. First, the data indicated that some patients had increased levels of negative symptoms and suspiciousness/hostility after one year. The results were partly in line with the findings in some of the previous studies which showed that the negative symptoms were relatively resistant to treatment as compared to the positive and affective symptoms (Hinkelmann et al., 2013; Möller, 2007; Üçok and Ergül, 2014). In addition, poor insight might underlie their persistent suspiciousness

4.2. Enhancing self-esteem of patients may facilitate improvements in social skills The present study showed that the patients who maintained a higher level of self-esteem at baseline would have a higher chance of making improvement in social skills (Table 4). These findings were consistent with our study hypotheses and the previous research findings that underline the importance of self-esteem as the major predictor of social functioning among people with mental illness (Borras et al., 2009; Davis et al., 2012; Hall and Tarrier, 2003). It may imply that self-esteem, which results from the interaction between self-evaluation and social feedback (Lecomte et al., 2006), should be targeted for intervention for helping those patients with long-term social dysfunctions to regain their motives/interests in social participation (Hall and Tarrier, 2003). Some studies have also suggested that self-esteem intervention groups could facilitate patients with chronic mental disorders to

Table 4 Logistic regression for exploring the baseline predictors of clinical improvement in social skills and work skills. Outcome

Improvement in social skills Improvement in work skills

Predictors, M (SD)

Affective symptoms (T0) Self-esteem (T0) Physical functioning (T0) Behavioral regulation (T0) Family's intrusiveness (T0) Discrimination experience (T0)

Group differencesa

Binary logistic regressionb

Patients with improvement (n1/n2 = 64/88)c

Patients without improvement (n3/n4 = 56/58)d

p

OR

95% C.I.

p

12.05 25.70 24.48 32.69 22.95 17.25

14.52 24.05 24.28 31.71 25.71 19.19

0.079 0.036* 0.029* 0.084 0.073 0.005*

1.01 1.15 0.54 0.53 0.96 0.87

[0.94, 1.08] [1.01, 1.30] [0.18, 1.62] [0.24, 1.18] [0.91, 1.02] [0.78, 0.97]

0.783 0.030* 0.270 0.120 0.190 0.011*

(7.72) (4.02) (1.10) (2.32) (6.30) (4.14)

(7.49) (4.48) (1.01) (3.50) (7.81) (3.81)

Note. The multivariate analysis controlled the effects of age, gender, education, duration of illness, diagnosis, participation in rehabilitation services, and the baseline score of social skills/work skills. a Either independent t-tests (for normally distributed data) or Man-Whitney U tests (for non-normally-distributed data) were used. b Models summary: Nagelkerke R2 = 0.18 and 0.20 for the logistic regression models predicting improvements in social skills and work skills, respectively. c n1 and n2 = no. of patients with clinical improvements in social skills and work skills, respectively. d n3 and n4 = no. of patients without clinical improvements in social skills and work skills, respectively. * p < 0.05.

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Table 5 Multiple linear regression for exploring the longitudinal predictors of change in social skills and work skills. Bivariate analysisa

Multiple linear regressionb

Dependent variable

Independent variable

r

p

B (95% CI)

β

p

Change in social skills

Change Change Change Change Change

0.15 − 0.20 − 0.13 0.11 0.25

0.017* 0.002* 0.050* 0.080 < 0.001*

0.72 (0.22,1.22) − 0.30 (− 0.52, − 0.09) 0.14 (− 0.19, 0.48) 0.07 (− 0.05, 0.19) 0.18 (0.08, 0.29)

0.17 − 0.18 0.05 0.07 0.20

0.005* 0.006* 0.402 0.240 0.001*

Change in work skills

in in in in in

physical functioning negative symptoms suspiciousness/hostility self-efficacy self-efficacy

Note. The multivariate analysis controlled the effects of age, gender, education, duration of illness, diagnosis, participation in rehabilitation services, and the baseline score of social skills/work skills. a Spearman's correlation coefficients were used to test the associations between each independent variable and dependent variable. b Models summary: Adjusted R2 = 0.28 and 0.24 for the regression models predicting change in social skills and work skills, respectively. * p < 0.05.

demands and participation in social activities (Kielhofner, 2008).

actively cope with their symptoms (Borras et al., 2009; Lecomte et al., 1999) and to appreciate their strengths (Freeman et al., 2014). This could enhance their motivation in coping with the real-life situations and performance in daily activities. Given that self-esteem lays the foundation of self-actualization of potentials (Maslow and Frager, 1987), the result in Table 6 might further suggest that patients with improvement of self-esteem might even seek improvement in the work skills that were part of their life roles (Davis et al., 2012). Although this relationship could be explained reversely, we suggested that improving basic work skills and self-esteem might complement each other in promoting readiness to work or actual performance in workplaces. This explanation is also plausible for the linkage between change in selfefficacy and change in work skills as shown in one of the multiple regression models (Table 5). According to self-efficacy theories, self-efficacy of individuals would indicate his/her coping effort and decisionmaking in accomplishing personal goals (Bandura, 1997; Liberman et al., 1986). Therefore, enhancing self-efficacy and work skills may enable an individual to have good judgment of one's capability in coping with different demands at work and reinforce a sense of autonomy and mastery over the work environment. Based on the present findings on the temporal relationship between baseline self-esteem and improvement in social skills, we suggested that individuals recovering from mental illness may benefit from interventions that target on self-esteem which is commonly weakened by their adverse social experiences and perceived stigmatization in the social environment (Bentall et al., 2012; Gracie et al., 2007; Selten and Cantor-Graae, 2005). Enhancing self-esteem of these individuals may facilitate them to rebuild their volition for coping with the task

4.3. Reducing discrimination may facilitate improvement in work skills Apart from the possible effects of self-esteem and self-efficacy, the present study showed that the discrimination experience in the social environment would undermine the positive changes and improvements in work skills among the patients (Tables 3 and 4). According to the attribution model, discrimination is the behavioral consequence of stigma that results from stereotypes and prejudices towards people with mental illness (Corrigan, 2000). It can limit their opportunities in many aspects of life, such as building interpersonal relationships and seeking employment. Since Chinese people place a high value on work identity (Yang et al., 2014), the volition of individuals with mental illness in participating in work or making improvement in work skills can be particularly hampered when people around them show suspicion of their functional status and their work productivity. In particular, people with mental disorders may experience various forms of discrimination in workplaces, such as humiliation, abuse, being discounted, and being overprotected by coworkers (Fornells-Ambrojo et al., 2014). These negative social experience could intensify their negative self-concepts and self-stigma, which in turn compromise their self-esteem and selfefficacy in the volition component (Kielhofner, 2008). Consequently, it poses a major barrier for people with mental illness to re-establish their work roles (Cechnicki et al., 2011; Henry and Lucca, 2004; Tsang et al., 2003). Thus, the findings may suggest that reducing the public stigma of mental illness would be useful for facilitating Chinese people with mental illness to reintegrate into the workplace and to re-establish their

Table 6 Logistic regression for exploring the longitudinal predictors of clinical improvement of social skills and work skills. Outcome

Improvement in social skills

Improvement in work skills

Predictors, M (SD)

Change in Change in Change in hostility Change in Change in Change in Change in

Group differencesa

Binary logistic regressionb

Patients with improvement (n1/n2 = 64/88)c

Patients without improvement (n3/n4 = 56/58)d

p

OR

95% C.I.

p

positive symptoms affective symptoms suspiciousness/

− 0.59 (3.75) − 1.33 (6.34) 1.00 (2.93)

1.95 (5.76) 0.55 (5.72) 1.96 (3.14)

0.006* 0.092 0.085

0.90 0.95 0.99

[0.81, 1.00] [0.89, 1.03] [0.85, 1.15]

0.048* 0.229 0.882

reaction to stigma self-esteem self-efficacy reaction to stigma

− 1.16 (5.49) 1.13 (3.69) 0.31 (6.30) − 1.05 (5.52)

0.75 (5.33) − 0.52 (2.90) − 2.53 (5.93) 1.17 (5.09)

0.057 0.005* 0.007* 0.016*

0.92 1.13 1.06 0.94

[0.85, 0.99] [1.00, 1.28] [0.99, 1.13] [0.87, 1.00]

0.036* 0.048* 0.100 0.068

Note. The multivariate analysis controlled the effects of age, gender, education, duration of illness, diagnosis, participation in rehabilitation services, and the baseline score of social skills/work skills. a Either independent t-tests (for normally distributed data) or Man-Whitney U tests (for non-normally-distributed data) were used. b Models summary: Nagelkerke R2 = 0.23 and 0.22 for the logistic regression models predicting improvements in social skills and work skills, respectively. c n1 and n2 = no. of patients with clinical improvements in social skills and work skills, respectively. d n3 and n4 = no. of patients without clinical improvements in social skills and work skills, respectively. * p < 0.05.

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between different diagnostic groups in the analyses and excluded those patients with chronic mental illness. Third, although this prospective study has identified some of the key variables in predicting changes and improvements in social skills and work skills, causality cannot be established from this quasi-experimental design. Researchers should conduct randomized controlled studies in the future to examine whether intervention targeted on self-esteem or perceived discrimination/ stigma of patients could facilitate their improvements in social skills and work skills, respectively. Some intervention studies have already provided initial evidence for using psychoeducation or cognitive behavioral therapy to enhance self-esteem (Borras et al., 2009; Hall and Tarrier, 2003; Lecomte et al., 1999) and reduce self-stigma (Fung et al., 2011) of patients, but further studies should be conducted to examine whether changes in these areas can transfer to improvement in specific areas of community functioning. In addition, our forthcoming study will conduct a path analysis from the available data to illustrate how different individual and environmental factors may interact with each other to affect changes in social skills and work skills of patients. Lastly, due to the limitations of secondary data analysis, the employment status and vocational history of patients were not collected. Future studies should incorporate these data to examine whether improvement in basic work skills is associated with improvement in employment outcomes among the patients.

work roles. The practice strategies may include promoting public acceptance of people with mental illness (Warner, 2005), reducing employer's concern about hiring individuals with mental illness (Tsang et al., 2010), decreasing stigmatization of vocational rehabilitation (Teng and Friedman, 2009), and incorporating self-stigma reduction and practical strategies to handle public discrimination as part of psychosocial or vocational rehabilitation services (Corrigan et al., 2006; Garske and Stewart, 1999). On the other hand, the present study showed that reducing the negative reactions to stigma (e.g., social withdrawal) might be useful for enhancing social skills (Table 6). Alternatively, the association might also indicate that patients who made improvement in social skills might reduce their negative reactions to stigma. Based on the findings from previous research (Eklund and Hansson, 2007; Siegrist et al., 2015), we suggest that patients with mental illness may benefit from group intervention that increase their frequency of social contact with other people such as their peers. This may create a social context for them to decrease their self-stigma of mental illness and to reconnect with other people in the social environment, which in turn enhance their motivation to participate in social activities and to make improvement in social skills. 4.4. Importance of maintaining physical health and controlling symptoms Apart from the above findings, our study indicated that change in social skills was associated positively with change in physical functioning and negatively with change in negative symptoms (Table 5), while improvement in social skills could be predicted by reduction of positive symptoms (Table 6). The findings that physical health problems and psychopathology would undermine various aspects of social functioning were consistently reported in the previous studies (Dixon et al., 2001; Pratt et al., 2005; Strauss et al., 2013). Some studies have also shown that patients with low level of self-esteem and external locus of control, which indicate poor volition (Kielhofner, 2008), might have poor coping effort with their positive or negative symptoms and dysfunctions in various social roles (Borras et al., 2009; Ciufolini et al., 2015). The additional evidence from this prospective study may provide support for the recent development of some psychosocial intervention to monitor the volition of clients in maintaining their physical health and effort in coping with the residual symptoms (Bernstein et al., 2016; Bressington et al., 2016; Rauch et al., 2009).

5. Conclusions

4.5. Strengths and limitations

Conflict of interests

Based on the findings from this prospective study, we suggest that enhancing the self-esteem of psychiatric patients may facilitate their improvement in social skills, while reducing their discrimination experience in the social environment may promote their improvement in work skills. Further studies are required to examine whether delivering rehabilitation services that targets on these areas for intervention are effective in promoting social skills and work skills for individuals recovering from mental illness. Acknowledgements Funding for this study was provided by the Commissioned Research on Mental Health Policy and Services (Project number: SMH-34), from Food and Health Bureau, The Government of Hong Kong Special Administration Region.

To the best of our knowledge, the present study was the first prospective study to analyze the multiple factors that might affect different areas of community functioning among Chinese psychiatric patients. The prospective study had objectively assessed different areas of community functioning of patients (i.e., self-care, community living skills, social skills, and work skills) and comprehensively analyzed their relationships with the volition, behavioral capacity and environmental contexts of patients under the framework of MOHO (Kielhofner, 2008). The findings from this study might inform the development of effective intervention services for Chinese people with common mental disorders to make improvement in community functioning, especially in social skills and work skills. However, there were several major limitations in this study. First, this study only recruited patients from three public psychiatric outpatient clinics who had past collaborations with the research team. The sampling bias may result in an under-representation of psychiatric outpatients in the local territory. Second, this study was conducted in a cohort of patients with mixed diagnostic categories. The study findings could not be generalized to specific diagnostic groups. Nevertheless, the findings could be generalized to the psychiatric outpatient population who were diagnosed with common mental disorders within a period of ten years, as we have controlled for the possible group differences

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