Post-hospitalization treatment adherence of schizophrenic patients: Gender differences in skill acquisition

PSYCHIATRY RESEARCH ELSEVIER

Psychiatry Research 69 (1997) 123-129

Post-hospitalization treatment adherence of schizophrenic patients: gender differences in skill acquisition Thomas E. Smith”“, James W. Hull”, Donna T. Anthony”, Marianne Goodmana, Andiea Hedayat-Harris”, Tracy Felger”, Mary K. Kentrosa, Sally J. MacKainb, Susan Romanelli” “Department of Psychiatry, Cornell University Medical College and Westchester Division, Neal York Hospital. 21 Bloomingdale Road, White Plains, NY 10605, USA hDepartment of Psychology, University of North Carolina at Wilmington, 601 South College Road, Wilmington, NC 284053297. USA

Received 4 March 1996;revised 2 July 1996; accepted 23 January 1997

Abstract

A cohort of acutely ill, hospitalized patients with chronic psychotic disorders participated in a study of a manualized community reintegration skills training program. Initial data analyses revealed that skill levels improved significantly over the course of treatment, and that higher post-training skill levels were associated with better post-discharge functioning for the group as a whole. Post-discharge treatment adherence rates were dramatically better in females, and analyses were conducted to determine the role of gender. Males and females had different predictors of post-training skill level and post-discharge treatment adherence. In males, who as a group were at higher risk for poor post-discharge outcome, there was a positive association between post-training skill level and post-discharge treatment adherence. Females, on the other hand, showed good post-discharge treatment adherence regardless of post-training skill or symptom levels. This report is consistent with prior studies suggesting that male and female individuals with schizophrenia show differential patterns of social skill, skill improvement, and social adjustment. 0 1997 Elsevier Science Ireland Ltd. Keywords:

Skills training; Community reintegration;

Social adjustment

1. Introduction Gender differences are well established in schizophrenia. As a group, females have a later

*Corresponding author. Tel.: + 1 914 9975962; fax: + 1 914 99759%. 0165.17X1/97/$17.00 0 1997 PII SOlf15-1781(96)03013-8

age of onset, better premorbid functioning, and a less debilitating course of illness (Angermeyer and Kuhn, 1988; Childers and Harding, 1990; McGlashan and Bardenstein, 1990). Psychotic symptoms are often less severe in females (Goldstein et al., 1989; Perry et al., 1995) and gender is related to social skill and social functioning (Angermeyer et al., 1990; Mueser et al.. 1990a,

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T.E. Smith et al. /Psychiatry Research 69 (1997) 123-129

1994). These and other findings suggest a more benign form of the illness in females (Haas et al., 1990). Male and female patients with schizophrenia may also respond differently to psychosocial treatments, although there are surprisingly little data in this regard. Mueser et al. (1990b) and Douglas and Mueser (1990) described a brief inpatient skills training program in which males improved their social skill performance significantly more than did females. In a skills training study by Hogarty et al. (1974) both males and females improved, but the great majority of relapsers were males. Similarly, Haas et al. (1990) described a study in which female patients showed greater functional improvement after participating in a family therapy program. These studies suggest that there may be gender effects on skill acquisition and generalization in psychosocial treatment programs, although the specifics of these effects remain unclear. Our group recently studied the feasibility of a new social skills training program, the Community Re-Entry Program, that teaches skills for engagement in aftercare treatment to hospitalized patients with schizophrenia or severe affective disorders (Smith et al., 1995). Initial data analyses suggested that: (a) acutely ill inpatients showed improvements in skill level that were independent of levels of psychotic symptoms; (b) post-discharge skill levels correlated with participation in the training module, suggesting a true learning effect; and (c) post-training skill levels were more predictive of post-discharge treatment adherence than symptom levels. In our study skill generalization was approximated by documenting post-discharge treatment adherence (attendance at aftercare program and medication compliance) in a subsample of the cohort for which follow-up records were available (Smith et al., 1995). Female patients showed much higher rates of posthospitalization treatment adherence as compared to males, and several anecdotal reports also indicated that males had a more difficult time engaging with aftercare treatment. Because of these findings, we conducted further analyses focusing specifically on gender effects. Our initial hypotheses were that female patients would show greater

improvements in skill level from pre- to posttraining, and that the better post-discharge adherence noted in the female cohort would be associated with higher post-training skill levels. 2. Methods Subjects were recruited from consecutive inpatient admissions to a psychotic disorders unit over a lo-month period, with a total of 44 subjects (23 males and 21 females) completing preand post-training assessments. Diagnoses were made by the treating psychiatrists; approximately 85% had DSM-IV diagnoses of chronic schizophrenia or schizoaffective disorder, with the remaining having either affective disorders with psychotic features or psychotic disorder not otherwise specified. Subjects were asked to participate in the Community Re-Entry Program (Liberman, 19951, which was described as a daily small group therapy program aimed at helping patients become more active in their discharge and aftercare planning. The program teaches skills necessary for symptom identification, medication management, and collaborative treatment planning, and includes a trainer’s manual, videotapes, and patient workbooks. The manual outlines strategies for instruction, modeling, role play and homework techniques that are used in 16 instruction sessions that cover topics including identifying warning signs and symptoms of disabling mental disorders; determining discharge readiness; making and keeping appointments; and evaluating the effects of medications. For the project, groups of four or five patients were led by one or two trainers, with 60-min sessions offered on a daily basis. Patients were asked to begin attending the group as soon as they had completed the pre-training skill assessment (see below), regardless of their symptom or medication status. Following each session, trainers recorded attendance and rated each patient for level of participation on a 3-point scale (0 = none; 1 = minimal; 2 = adequate). Although all patients were strongly encouraged to attend, there were no specific rewards or sanctions tied to attendance. All trainers followed the manual dur-

T E. Smith et al. /Psychiatry Research 69 (1997) 123-129

ing each session, and intermittent group observation by senior staff and weekly trainers’ meetings were used to maintain trainer fidelity. The assessment battery included measures of positive and negative symptoms as well as ratings of the community reintegration skills taught in the Community Re-Entry Program. The battery was administered on admission to the inpatient unit and again at discharge. Symptom ratings were made with the Scale for the Assessment of Positive Symptoms (SAPS) and Scale for the Assessment of Negative Symptoms (SANS) (Andreasen, 1984, 1984). Raters participated in a training program involving rating of tapes produced by the developers of the SAPS and SANS, and interrater reliability was documented with intraclass correlation coefficients for each of the global subscale ratings as follows: affective flattening, 0.78; alogia, 0.68; avolition-apathy, 0.65; anhedoniaasociality, 0.67; attention, 0.94; hallucinations, 0.87; delusions, 0.46; bizarre behavior, 0.52; and formal thought disorder, 0.77. Mean global subscale scores from the SAPS and SANS at each assessment were used as measures of positive and negative symptom levels for data analyses. Ratings for the skills taught in the training module were made using a test of social perception and problem-solving skills presumed to underlie patients’ abilities to manage symptoms and adhere to treatment. A structured interview, developed for the program, included 29 questions and role plays addressing each of the topics covered in the manual (medication management, symptom management and collaborative discharge planning). Interviewers asked questions and initiated role plays, and then recorded the patient’s responses verbatim. Separate raters, who were blind as to whether the interview was part of a pre- or post-training assessment, scored the verbatim responses based upon the presence and absence of specific behavioral or informational responses. As an example, one question asks the subject what medications he/she is taking. The rater awarded two points for responses correctly identifying both the subject’s medications and class (e.g. antipsychotic vs. antidepressant), one point if the subject could only describe classes of medications he/she was taking, and no points if

125

the subject gave neither correct response. Interrater reliability for this instrument was tested by having a second rater score the first 10 cases; the intraclass correlation coefficient for the total score was 0.92. Thirty-three patients had follow-up records available for ratings of post-discharge treatment adherence. These data were gathered using telephone follow-up interviews 2 weeks after discharge with family members, outpatient treatment providers, and community residence staff. Two senior staff members blindly rated the narratives, categorizing patients as either community ‘adjusters’ or ‘non-adjusters’ based upon: (al attendance at aftercare programs; and (b) medication compliance, during the first 2 weeks post-discharge. Patients were rated as ‘non-adjusters’ if they missed any follow-up appointments or demonstrated problems complying with prescribed psychotropic medications. Agreement between the raters was high (940/c), with disagreements resolved following review and discussion. 3. Results 3.1. Gender differences on skill levels with training Table 1 lists mean symptom levels and total skill scores prior to and upon completion of training for the entire sample. Males and females did not differ significantly on total positive and negative symptom scores nor any of the SAPS and SANS subscale scores on admission to the study. There were also no significant gender differences at pre-test on the total skill score. Both males and females showed significant decreases in positive symptoms and non-significant improvements in negative symptoms throughout the hospitalization period (Table 1). Both groups also showed significant increases in total skill level after training. Males and females did not differ in ratings of participation in skills training groups, with the male group showing a mean participation score of 1.65 (S.D.= 0.161 and females 1.66 (SD.= 0.27) on the 3-point scale. Upon completion of the training program males and females did not differ significantly on total positive symptom scores, any of the SAPS subscales, or total skill level. How-

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T.E. Smith et al. /Psychiatry Research 69 (1997) 123-129

Table 1 Symptom and skill levels in hospitalized males and females participating in skills training program Pre-training

Post-training

d.f.

t

P

Males (N = 23) Mean positive symptom score Mean negative symptom score Total skill level

1.8 (0.9) 2.4 (0.9) 18.8 (8.7)

1.1 (0.9) 2.0 (0.9) 25.7 (6.3)

18 18 22

3.98 1.24 - 4.73

0.002 N.S. 0.001

Females (N = 21) Mean positive symptom score Mean negative symptom score Total skill level

1.9 (0.8) 1.4 (1.2) 21.1 (9.2)

0.9 (0.7) 0.8 (0.5) 28.6 (5.1)

11 11 20

5.06 2.14 - 4.56

0.001 N.S. 0.001

ever, the female group had a significantly lower total negative symptom score at discharge (t[40] = 2.63, P < 0.051, which was accounted for by differences in the SANS subscales of alogia (t[40] = 1.75, P < 0.091, avolition (t[40] = 2.18, P < 0.05), and flat affect (t[40] = 2.87, P < 0.01). 3.2, Models for post-training skill level by gender A regression model was created with post-training skill level as the dependent variable and pretraining skill level, gender, degree of participation in training, and a gender-participation interaction variable entered sequentially as predictors. The overall model was significant, accounting for 50% of the variance (E;4,s9= 11.64, P < 0.001). Significant individual predictors included pre-training skill level ( /3 = 0.45, P < 0.0011, participation ( p = 0.99, P < 0.0081, and gender (p = 1.60, P < 0.05). The gender-participation interaction variable approached significance (p = - 1.68, P < 0.069). Because of the order in which predictors were entered into the model, this analysis may be viewed as a test of the gender-participation interaction, after other predictors, including pre-training skill level, had been taken into account. These findings suggest that participation in the training program predicted post-training skill level (in the expected direction) above and beyond pre-training skill level, and that this effect was greater in males than females. In post-hoc exploratory analyses we tested whether positive and negative symptom levels at post-training added significantly to the prediction

of post-training skill levels, above and beyond the effects of gender, participation, and pre-training skill level. Neither positive nor negative symptoms made significant incremental contributions. Separate regression models were then generated for males and females, modeling post-training skill level with pre-training skill level, degree of participation in training, and positive and negative symptom levels as predictors. For males, post-training skill level was significantly and positively associated with pre-training skill level and degree of participation in the program ( p = 0.48, P < 0.008 and p = 0.48, P < 0.007, respectively) in an overall model that accounted for 56% of the variance in post-training skill level (F4,rs = 7.96, P < 0.001). For females, however, the new overall model accounted for only 25% of the variance (F4,r4 = 2.49, P < 0.10). The only significant predictor was pre-training skill level ( /? = 0.52, P < 0.03). 3.3. Gender differences in post-discharge treatment adherence

To model outcome, a logistic regression analysis was carried out with post-discharge adherence status as the dependent variable and pre-training skill level, gender, participation in the training program, and a gender-participation interaction variable entered as predictors simultaneously according to the likelihood ratio criterion. For comparisons involving gender, females were the reference group. The final model was significant and correctly classified 88% of the subjects ( x2 =

T.E. Smith et al. /Psychiatry Research 69 (1997) 123-129

17.22, d.f. = 1, P < 0.001). The participation variable did not enter into the model, but all other predictors were significant (Table 2). The magnitude and direction of the adjusted odds ratios (see Table 2) give some indication of the relative importance of these predictors in the final model. Increasing increments of skill improved the odds of being categorized as having good post-discharge treatment adherence, while being male led to a dramatic drop in odds. Only 53% of the male patients were classified as ‘good adjusters,’ as opposed to 93% of the females. The very high odds ratio for the interaction term suggested that increasing increments of participation in skills training led to much greater improvement in post-discharge treatment adherence in males, compared to females.

The data from this study also suggest significant gender differences in the predictors of skill level and functional capacity, but our hypotheses that females would demonstrate greater posttraining skill levels and stronger associations between post-training skill and post-discharge treatment adherence were not supported. The male patients showed significant associations between group participation and post-training skill level, and also between post-training skill level and post-discharge treatment adherence. The female cohort, on the other hand, showed a substantially higher rate of good post-discharge treatment adherence as compared with males but no significant associations between group participation, post-training skill level and functional outcome. Our results are in fact consistent with those from the three previous studiesthat documented gender effects in psychosocial treatment programs (Hogarty et al., 1974; Haas et al., 1990; Mueser et al., 1990a): males showed more signs of clear benefit from the training, yet females showed better post-treatment functioning, suggesting that factors other than the skills targeted by specific psychosocial treatment programs are stronger determinants of social adjustment in females. Prior research indicates that there are differences in social adjustment in male vs. female patients with schizophrenia, with studies documenting differences in role expectations and family attitudes (Angermeyer et al., 1990; Haas et al., 1990;

4. Discussion The data from this study suggest that, like skills symptom levels, symptom management change significantly over the course of treatment for an acute exacerbation of a chronic psychotic disorder. Comparing males and females in our sample, there were no differences on skill level, positive or negative symptoms on admission to the study. Both males and females showed significant increases in skill level and decreases in positive symptoms after training, and the female group had a significantly lower negative symptom score upon the completion of training.

Table 2 Logistic regression analysis of post-discharge treatment symptom management skills training (N = 33).

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adherence

in a cohort

of chronic

psychotic

disorder

patients

receiving

_ Predictor

Adjusted

Pre-training skill level Gender Gender-participation

1.12 < 0.01 1329 894

Model when predictors Predictor Pre-training skill level Gender Gender-participation

odds ratio

Wald test

d.f.

P<

3.33 3.Y3 3.41

1

0.07

I I

0.05

d.f. 1

P< 0.05 0.02 0.04

0.07

are removed Likelihood 3.89 5.58 4.48

The lower half of the table lists x2 values and significance

ratio

x’

1 1 when individual

predictors

are removed

from the equation.

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T.E. Smith et al. /Psychiatry Research 69 (1997) 123-129

Mueser et al., 1990a; Chaves et al., 1993; Mueser et al., 1993) that likely contribute to bettter adjustment in females. In our cohort it is likely that the factors described in these other studies facilitated post-discharge treatment adherence in the female group. Our data suggest a different pattern for males, however. The male group had a much lower rate of good treatment adherence at follow-up, yet group participation and post-training skill level were significantly associated, and post-training skill level remained a significant predictor of treatment adherence. This suggests that males benefited from the skills training program, showing a logical progression from skill acquisition to utilization. In the absence of a no social skills training group and data on pre-hospital treatment adherence, however, such interpretations are only preliminary. There are several other methodological weaknesses in this study which limit interpretation of these data. These include the small sample size and the failure to account for the other variables, including pre-hospital adherence and support persons’ attitudes and role expectations, that are likely to influence community treatment adherence of an individual with schizophrenia immediately following discharge from an inpatient unit. Nonetheless, the data are interesting in that they suggest different pathways by which male and female patients suffering from acute psychotic exacerbations improve symptomatically, develop and utilize symptom management skills, and adjust to post-hospitalization community functioning. Further research will clarify the pathways by which focused skills training interventions influence the process of recovery from acute psychosis.

Acknowledgements

The authors thank Robert P. Liberman and Charles J. Wallace of the UCLA Clinical Research Center for Schizophrenia and Psychiatric Rehabilitation for consultation and use of the skills training module, This research was sup-

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