International Review of Psychiatry (1998), 10, 58± 61

The effect of symptom self-management training on

rehospitalization for chronic schizophrenia in Finland

JAN-HENRY STENBERG,1 IIRO P. JAÈ AÈ SKELAÈ INEN2 & RUNE ROÈ YKS2

1Hesperia Hospital, Department of Adolescent Psychiatry, Helsinki & 2Unit of Psychiatry, Clinic for

Rehabilitation, Espoo, Finland

Sum mary

The effect of symptom self-management training (SSMT) was studied on several indices of quality of life, global functioning, and

on the number and length of hospitalizations in patients suffering from chronic schizophrenia in Finland. It was hypothesized that

less severe and disruptive relapses would result from the SSM T patients and their relatives being taught to recognize `warning signs’

that precede a psychotic episode and to contact medical staff before a full-blown psychosis commenced. The 29 patients receiv ing

SSMT treatment did not signi® cantly differ in quality of life or function ing from the 18 comparison patients. The number of

hospita lizations, re¯ ecting the number of relapses during the follow-up of 1± 2 years, was not different between the treatment and

comparison groups, either. However, the length of hospita lization per admission, re¯ ecting the severity of relapses, was signi ® cantly

shorter in SSM T patients.

Introduction

While antipsychotic medication is probably the main

protective factor against development of psychotic

symptoms and relapse (see Liberman, 1994),

patients on adequate doses of neuroleptic medi-

cation still have unacceptably high rates of relapse

(Hogarty, 1984). For example, patients receiving

guaranteed delivery of antipsychotic medication

through long-term, injectable or depot antipsy-

chotics, still show relapse rates of approximately

40% per year (Hogarty et al., 1986). Furthermore,

medication cannot teach patients how to cope with

a stressful life, or how to function successfully in

society (Liberman, 1994); thus, developing effective

psychosocial rehabilitation methods to complement

drug therapy is an important goal in schizophrenia

treatment research.

Symptom self-management skills training

(SSMT) is a rehabilitation method that aims to

delay, mitigate or prevent psychotic relapses in per-

sons with schizophrenia (Eckman et al., 1992;

Liberman, 1989; Marder et al., 1996). This module,

from the UCLA Social & Independent Living Skills

Program, is an educational program for teaching

schizophrenic patients and their relatives speci® c

types of knowledge and skills to help them in coping

with the disease. The topics, or skill areas, of the

module include: (1) identifying personal warning

signs of a psychotic relapse, (2) managing the warn-

ing signs with a relapse prevention plan, (3) coping

with persistent symptoms, and (4) avoiding alcohol

and street drugs. The module can be taught to

individual patients, to patients and their relatives,

and to groups.

The purpose of the present study was to investi-

gate: (1) the effect of the SSMT program on the

frequency and severity of relapses as indexed by the

number and length of hospitalizations in a Finnish

population of schizophrenics; (2) whether SSMT

affects the patients’ self-reported quality of life; and

(3) the impact of the SSMT on the global function-

ing of the patients.

Methods

Subjects

From a total of 47 hospitalized voluntary patients,

all meeting DSM-III-R criteria for schizophrenia,

who participated in their standard and individual-

ized treatment programs, 29 were assigned to also

participate in the SSMT program, during 1992±

1994, in the Clinic for Rehabilitation, at Jorvi Hos-

pital, in Espoo, Finland. Patients receiving SSMT

and standard treatment were matched into three

sub-groups on the basis of the starting point of the

SSMT program, with a resulting length of follow-up

assessm ents ranging from 1± 2 years. As shown in

Table 1, there were no statistically signi® cant differ-

ences between the SSMT and matched control

groups in sex, age, marital status, level of education,

diagnostic sub-type, age of onset of schizophrenia,

the number of prior hospitalizations, and the time

spent in mental hospital per hospitalization.

Based on self-report and con® rmed by medical

chart review, the medication of the patients was

classi® ed into four categories: (1) conventional neu-

roleptic; (2) atypical neuroleptic (clozapine); (3)

antianxiety; and (4) antidepressant drugs. There

Correspondence to: Rune Royks, MA, Unit of Psychiatry, Clinic for Rehabilitation, Postipuuntie 2, FIN-02600, Espoo,Finland. Tel: 1 358 9 861 7520. Fax 1 358 9 861 7535.

0954± 0261/98/010058± 04 $7.00 Ó 1998, Institute of Psychiatry

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Symptom self-management training in schizophrenia 59

Table 1. Demographic variables of SSM T and control patients. Values are presented as mean

( 6 SEM ), or as frequencies

Variable SSMT Control

Total number of patients 29 18Male female ratio 17/12 10/8Age 35.3 6 1.5 32.4 6 2.3Age of onset of schizophrenia 24.9 6 1.1 21.7 6 1.5Number of hospitalizations (in weeks) 7.2 6 0.6 11.2 6 2.4Length of hospitalizations (in weeks) 4.9 6 0.7 6.6 6 1.4Number of patients on antipsychotics all allNumber of patients on adjunctive benzodiazepines 23/29 13/18Number of patients on antidepressants 5/29 none

Table 2. The self-and staff-rated variables for the SSMT and control patients

SSMT Controls

Self-rated variablesContentment with treatment 7.6 6 0.4 6.7 6 0.3Bene® t of treatment 7.6 6 0.3 7.6 6 0.3Contentment of present state of life 6.8 6 0.4 6.8 6 0.5

ª 2 years ago 5.6 6 0.4 6.1 6 0.7ª 2 years from now 7.4 6 0.3 6.8 6 0.8

Support of family 7.4 6 0.4 7.8 6 0.5Capability to identify warning signs 7.4 6 0.4 6.6 6 0.5Capability to cope with illness 6.6 6 0.4 6.3 6 0.8Alcohol consumption (standard drinks) 3.1 6 0.8 1.8 6 0.8Quality of life scale 7.8 6 0.3 6.5 6 0.6

Staff-rated variablesQuality of life scale 7.2 6 0.3 6.1 6 0.6GAF evaluation 42.8 6 1.9 39.4 6 2.1

were no statistically signi® cant differences between

the SSMT and control groups’ medication during

the study.

Assessments

The data were gathered by interviewing the patients,

analyzing their medical histories, and asking the

treatment staff to evaluate the interviewed on their

personal assessments of outcome with a semistruc-

tured format, using a 10-point Likert scale

(10 5 highest). The following self- and staff-

reported variables were gathered: (1) the patient’ s

contentment with his/her present treatment; (2) the

patient’ s estimation of the bene® t of his/her present

treatment; (3) the patient’ s contentment with his/

her present state of life; (4) the patient’ s content-

ment with his/her state of life before the SSMT; (5)

the patient’ s estimation of contentment with life two

years after the interview; (6) the patient’ s estimation

of support by his/her family; (7) the patient’ s esti-

mation of his/her capability to identify the warning

signs of the illness; (8) the patient’ s estimation of

his/her capability to cope with the disease; and (9)

consumption of ethyl alcohol (estimated in standard

drinks (12g of ethanol per drink).

Further, they were asked to evaluate their quality

of life (Spitzer et al., 1981). In addition, the treat-

ment staff evaluated the patients’ global functioning

with the GAF Scale and patients’ quality of life with

the same scale used by patients in their self-report.

The interviews and evaluations were made, with

three months accuracy, 2.0, 1.5 or 1.0 years after

the SSMT program. The number and duration of

patients’ hospitalizations were recorded for follow-

up periods of 2.0, 1.5 or 1.0 years after the SSMT

program.

Data analysis

The statistical analysis was conducted with two-

factor ANOVAs, with repeated measures on the last

factor. The factors were treatment (SSMT patients

versus controls), and length of follow-up.

Results

The self- and staff-reported ratings of quality of life,

and ratings of global functioning did not

signi® cantly differ between the SSMT and the con-

trol groups. In Table 2 are presented the values of

the self- and staff-report ratings.

The length of follow-up (2.0, 1.5 and 1.0 years)

signi® cantly in¯ uenced neither the number of hospi-

talizations nor the time spent in hospital per hospi-

talization. Further, the number of hospitalizations

was not signi® cantly different between the SSMT

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60 Jan-Henry Stenberg et al.

Figure 1. The time (in weeks) spent in 24-hour mental hospita l per hospitalization by patients with symptom self-management training

and by control patients treated with only conventional methods. The two groups did not signi ® cantly differ in baseline, but the SSMT

patients’ average time spent in hospital per hospitalization was signi® cantly shorter during the follow-up period, compared with the control

group (n 5 29 for the treatment group, and n 5 18 for the control group; error bars disclose the SEM ).

and the control groups (SSMT 5 1.9 6 0.3; con-

trols 5 2.7 6 1.2). The length of treatment per hos-

pitalization was, however, signi® cantly shorter in the

SSMT group than for the control group, as shown

in Figure 1, [F(1,41) 5 13.7, p , 0.001].

Discussion

Although there were some statistically insigni® cant

tendencies towards higher scores in self- and staff-

reported indices of the quality of life and global

functioning in the SSMT patients compared with

controls, no clear differences were observed between

the groups. The number of hospitalizations was not

signi® cantly different between the SSMT and con-

trol patients, either. The average length of hospital-

izations was, however, signi® cantly shorter in the

SSMT patients, compared with controls. In fact, the

schizophrenics who had participated in SSMT spent

only about 2.6 weeks in a mental hospital per

admission during the follow-up period of 1.0 ± 2.0

years, whereas the control patients’ corresponding

® gure was 20.1 weeks.

Tentatively, we might infer that this ® nding of less

severe and briefer relapses might have been related

to one of the central goals of SSMT; namely, teach-

ing the patients and their relatives to recognize

speci® c `warning signs’ that had preceded their prior

episodes of schizophrenic psychoses (e.g. insomnia,

restlessness) and to contact medical staff in case the

frequency of the occurrence of the signs increased

(Liberman, 1989). Consequently, the SSMT

patients could be admitted to mental hospital while

still being in the prodromal phase of their relapses,

compared with the controls, thus explaining the

longer periods of hospitalization needed by the con-

trols for a suf® cient recovery to allow clinical

improvement. This is consistent with recent ® ndings

from a controlled clinical trial of the Symptom and

Medication Management modules with low dose

¯ uphenazine decanoate (Marder et al., 1996).

It has to be noted that in Finland the treatment of

psychiatric patients involves relatively easy access to

24-hour hospital care. Thus, a major psychotic epi-

sode is not necessarily required for admittance, but

short hospitalizations may be used in monitoring

patients with prodromal or relatively mild signs of

relapse, and for preventing severe decompensations.

The data of the present study do not, however,

allow a rigorous analysis of the causal factors under-

lying the shorter length of hospitalization per relapse

in SSMT patients, and thus this needs to be

addressed in future investigations. In fact, the sever-

ity of psychopathology was only indirectly and glo-

bally rated in this study; hence, it is not even

possible to equate each hospitalization to a symp-

tomatic relapse or exacerbation (Falloon & Liber-

man, 1983).

Acute psychotic relapse in schizophrenia may lead

to a long-lasting loss of functional capacity, which

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Symptom self-management training in schizophrenia 61

produces disability and may predispose individuals

to future relapses. Thus, given the detrimental role

of relapses in chronic schizophrenia, the SSMT

treatment may have bene® cial long-term effects in

the treatment of this disorder in that it appears to

confer protection, along with antipsychotic medi-

cation and other conventional rehabilitation meth-

ods, for the patient in avoiding further psychotic

episodes.

Acknowledgements

The authors acknowledge Marjukka Stenberg for

helpful comments on the paper. The authors thank

also the nursing staff of Jorvi Hospital, Department

of Psychiatry, who have helped in this study.

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