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Literature Review

Occupational Therapy and First-Episode Psychosis: A Literature

Mariam El-saj
Australian Catholic University, New South Wales, Australia

First-episode psychosis (FEP) refers to the increase occupational functioning in
first occurrence of psychotic symptoms people experiencing FEP (Renwick, et al.,
that manifests in an individual for at least a 2017). This suggests that in areas of
week and/or results in a hospital occupational therapy, quantitative and
admission. Psychosis is characterized by qualitative research studies that focus
an inability to distinguish between reality directly on occupation-based interventions
and imaginary and encompasses a for people with FEP can provide important
collection of symptoms ranging from information on effective interventions for
delusions, hallucinations, disorganised increasing occupational participation. For
thinking as well as other functional the purpose of this review, the terms ‘first-
problems such as lack of motivation, social episode psychosis’, ‘early psychosis’,
withdrawal and sleep disturbances (DSM- ‘recent onset of psychosis’ are all used
5). Psychosis tends to occur as a precursor interchangeably. The purpose of this
to other forms of mental illness such as review was to explore the range of peer-
schizophrenia, highlighting the importance reviewed publications in relation to the
of early intervention (Hitch, Pepin, & various occupational therapy interventions
Stagnitti, 2013; Penn, Waldheter, Perkins, available for people with a recent-onset of
Mueser, & Lieberman, 2005). psychosis. The research question that
guided this literature review was:
A major concern in the management of
early psychosis is the significant impact it ‘What interventions are available to
can have on a person’s ability to occupational therapists working with
participate in occupational activities (Hitch people experiencing First-Episode
et al., 2013). Although 75% of people with Psychosis?’.
FEP enter clinical remission within the
first 6 months, 79.8% exhibit no functional Methods
recovery in this period (Penn et al., 2005). Search strategy
This suggests that improvement of
psychotic symptoms does not ensure better A comprehensive search of the Cinahl,
occupational functioning. Despite Medline and Psychinfo databases was
pharmacological treatment, functional conducted using the search terms
impairments continue to impact presented in Table 1. In tandem with these
individuals for up to 5 years following a search terms, major headings of
recent onset of psychosis (Penn et al., ‘psychiatric disorders’, ‘occupational
2005). therapy’ and ‘occupational therapists’ were
also included in every database to conduct
In recent years, various studies have found the search. In addition, the reference lists
that occupational based interventions
of papers were reviewed for other relevant A total of 10 articles were included in this
publications. review; 1 qualitative 9 quantitative studies.
It is presented in sub-themes based on the
Table 1: Search terms used for all databases
different areas of focus for intervention.
List of search terms Four articles were about the use of
1. “First episode psychosis*” OR “psychosis*” vocational interventions, three articles
OR “psychiatric disorder*” were about psychosocial interventions and
two focused on leisure-based occupations.
2. “occupational therapy” OR “occupational
function*” OR OT Occupational therapy intervention
3. “intervention” OR program* OR therap* Vocational intervention
There were four articles that focused on
Selection criteria the vocational outcomes of occupation-
based interventions. Three of these were
Inclusion criteria included articles relating specific vocational interventions, and one
to occupational therapy practice, early of these was an occupational therapy day
psychosis, early intervention for early programme known as the ‘Early
psychosis, and acute psychosis. Only Assessment Service for Young People
articles that consisted of peer-reviewed with Psychosis’ (EASY) (Poon, Siu, &
journals, in English between 1999 and Ming, 2010). This study evaluated the
2017 were included. Opinion pieces, outcomes of the intervention in relation to
editorials, magazine articles, and literature work and education three months after
reviews were excluded. Studies relating to discharge from the EASY programme. It
a general diagnosis of psychosis were also found that 79 out of 147 participants were
excluded. able to maintain productive roles with 64
maintaining employment or vocational
Analysis training. However, Poon et al. (2010)
Critical appraisal included participants with a diagnosis of
psychosis and schizophrenia, limiting the
Each of the research studies used in the accuracy of the findings. An additional
review was critically appraised using the limitation is the use of a retrospective
Curtin University guidelines as it assisted design impacting on the reliability of the
with determining the trustworthiness of the evidence presented. The last four studies
research presented (Burls, 2009). Based on evaluate the effectiveness of a specialist
the hierarchy of evidence by the National vocational intervention following an onset
Health and Medical Research Council of first episode psychosis (Major, et al.,
(NHMRC), most articles used are a level 3 2010; Rinaldi, et al., 2004; Killackey,
as they consist of cohort and retrospective Jackson, & McGorry, 2008). All three
studies with one being a level 4 (practice articles base their vocational intervention
evaluation study) and two articles being a on ‘supported employment’, the main
level 2 (small randomised controlled trial vocational model of choice. Major et al.
(RCT) and a prospective study). (2010) used a multidisciplinary early
intervention known as VIBE (Vocational
Results Support Within Early Intention) which is
led by an occupational therapist. It is
consistent with the supported employment
model and hence, the study’s hypothesis enhance socio-occupational functioning in
has been tested previously by the other two people with first episode psychosis
articles in this category. Killackay et al. (Parlato, Lloyd, & Bassett, 1999; Na, et
(2008) and Porteous and Waghorn (2007) al., 2016; Turner, et al., 2008). The
highlighted the effectiveness of individual REACH (Recognition and Eastern through
and supported employment as a useful Accommodation, Catering and
intervention for those with first episode Horticulture) program, the Young
psychosis using a randomized controlled Occupations Unlimited (YOU) and the
approach. Although this study found that Mind Flower Programs involve early
vocational intervention (individual and interventions with focus on building social
supported employment) was more networks and connecting with the
effective in gaining employment for community. The YOU programme is
participants with first episode psychosis consistent with the Model of Human
(17 out of 20) when compared to Occupation (Kielhofner, 1992) and thus,
participants who received treatment as focuses on all areas of an individual’s life
usual (2 out of 21), the study had a small by providing them with opportunities to
sample size of only 40 participants, participate in meaningful occupations.
limiting the generalizability of the Parlato et al. (1999) revealed that out of 21
findings. In comparison to the study by participants, 14 moved onto more
Rinaldi et al. (2004), a collection of 40 productive roles such as paid employment,
participants were also used to assess education and joining new groups as a
vocational outcomes at 12 months (as well result of the YOU programme. In
as 6 months) and concluded that there was comparison, the REACH programme also
a significant increase of patients reflected significant improvements in
participating in work. Porteous et al. patients over 4 years, however,
(2007) assessed vocational outcomes over psychosocial functioning was measured
4 years that also demonstrated an increase using the Global Assessment of
in employment for people with FEP by Functioning (GAF) scale which was also
10%. Other limitations common to three of used by Na et al. (2016). As a result, it
the intervention studies included the use of does not determine the outcome in relation
a cohort study design, practice evaluation, to actual level of occupational
small sample sizes and the use of mixed participation, hindering the usefulness of
populations of both FEP and the intervention in OT practice. However,
szhizophrenia. In summary, these articles the study contributes to the demand for
are central to occupational therapy as it more OT RCTs in the area of psychosocial
provides relevant insight on the interventions for people with early
importance of vocational interventions in psychosis as it highlighted the potential
maximising productive roles and overall sampling bias that may occur when a non-
occupational participation in people randomized controlled trial is taken
experiencing a recent onset of psychosis. (Turner, et al., 2008). The MFP offers a
range of services including group
Psychosocial intervention
programmes, reading clubs and physical
Three of the articles focused on increasing fitness clubs (Na, et al., 2016). The study
occupational participation through the use showed that with consistent participation
of psychosocial interventions. They all in the program (twice a week), at the 12
utilised community-based programmes to month follow up, no users had relapsed
and rate of employment and school psychosis. Conversely, Monique et al.
attendance increased to 57.1% (baseline of (2016) studied the effectiveness of
28%). A limitation of the study includes utilizing music tempo during OT treatment
the non-use of a control group as these of people with acute psychosis. Although
changes may have been due to various the findings did not suggest that music
other factors such as psychotherapy or listening during occupational therapy,
continued medication. Other common increases activity participation in people
limitations between these three articles is with psychosis (56.3% of participants), it
the small sample sizes and lack of suitable highlighted the importance of controlling
outcome measures. factors such as providing music of choice
to the participants. It also showed that in
Leisure based intervention
some cases of psychosis, the use of music
The two articles that highlighted the may increase activity participation as
application of leisure-based occupations ‘attention’ and ‘following of instructions’
for the treatment of early psychosis were both improved as a result of fast and
included the use of participatory slow music. This could manage symptoms
photography and music (Maniam, and facilitate the treatment goals for
Kumaran, Lee, Koh, & Subramaniam, consumers with early psychosis. In
2016; Strauss, Heerden, & Joubert, 2016). addition, both studies contributed to the
The qualitative study by Maniam et al. gap that exists on the use of music during
(2016) utilized ‘photovoice’ in conjunction occupational therapy and participatory
with an ‘Early Psychosis Intervention photography for people with early
Program’ (EPIP) as a method of increasing psychosis. Despite the study’s use of the
social participation and community term ‘psychosis’ to refer to the
engagement. Photovoice refers to a participants, the study population used in
photographic documentation of an the study were mental health consumers
individual’s everyday life as a way of who were newly admitted into the acute
expressing their emotions and thoughts. It psychiatric ward for acute psychosis and
involves participating in groups and for this reason, it was not excluded. Other
sharing narratives. Through the use of limitations were the use of participants that
interviews to collect the participants’ continued to take antipsychotic
experiences of photovoice with EPIP, the medication, influencing their reactions and
authors categorized their responses into symptoms to the music intervention.
different themes. Findings revealed that
participants achieved a sense of confidence Discussion
and self-esteem after participating in the The articles in this review suggest an
group session as it allowed them to receive important role for occupational therapy
social support. This article showcased interventions in relation to FEP. Other
important findings as it reiterated the literature regarding occupational therapy
importance of client centred care in the practice in FEP highlight the importance of
provision and implementation of activity and social engagement for full
occupational therapy intervention. The functional recovery, however lacks
main limitation of this study involves the recognition of interventions necessary to
small sample size of only 11 participants achieve such outcomes. It is important for
affecting the generalisability to the occupational therapists to understand the
population of people with first episode types of intervention as it will have an
impact on the outcome of treatment as well included because they addressed
promote client centred care in practice. As occupational functioning as an outcome
evident in the results, majority of the and used occupation-based interventions
interventions were based around (Na, et al., 2016; Killackey, et al., 2008;
vocational rehabilitation as they also Rinaldi, et al., 2004). Other limitations
reflected better quality studies and thus, involved the inclusion of an article that
higher levels of evidence around the used ‘acute psychosis’ as a population
effectiveness of outcome treatments. On (Strauss, et al., 2016). However, they were
the other hand, studies on psychosocial included as these participants were newly
interventions for early psychosis were admitted into the ward. Lastly, there was
limited and had questionable outcomes due one article that was not an outcome study
to inefficient outcome measures and lack but recommeded a useful intervention for
of control groups, demanding the need for practice (Parlato, et al., 1999).
evidence-based research. However, they
demonstrated a range of different Conclusion
approaches over the years that OT’s utilize The papers in this review provide an
in practice today. Central to OT is the art inventory-like tool for OT’s working with
of meaningful occupational participation, people that have experienced a recent-
which in many people is reflected through onset of psychosis. The findings of this
leisure-based occupations. Only two review must be considered as a baseline
studies were found on the use of leisure for further research on various occupation-
interventions to promote functional based interventions, moving beyond
recovery for first-episode psychosis, both vocational based and more onto leisure and
indicating promising results for effective psychosocial as they provide a clear
occupation-based interventions designed direction for exploration due to the gaps in
for OT’s. This highlights the need for research that exists. In addition,
more research on the utilization of leisure- incorporation of more flexible occupation-
based activities to promote socio- based therapies for increasing participation
occupational participation in people with ensures future OT’s adopt a client centred
first-episode psychosis. approach. There is promising opportunity
for development of various occupational
therapy interventions in the area of mental
Three articles were not occupational health and first-episode psychosis.
therapy specific however, they were
Appendix 1