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Psychiatry and Clinical Neurosciences (2002), 56, 609–615

Regular Article

Factors of good outcome after discharge from supporthouse (engoryou) for schizophrenia

SHINOBU SAKIYAMA, md,1 JUNZO IIDA, md,2 YOSHITAKE MINAMI, md3

AND TOSHIHUMI KISHIMOTO, md2

1Mie Mental Health Center, Hisai, Mie, 2Department of Psychiatry, Nara Medical University, Kashihara,Nara

and 3Touyoukai Kijimi Hospital, Kaizuka, Osaka, Japan

Abstract To restore mentally disabled persons to social activities, it is necessary to establish an appropri-ate facility and support system according to the severity of disorder. In the present study, in anattempt to obtain a guide to identifying conditions on which the use of the support house (engo-ryou) is effective, patients who had been discharged from the support house were divided intodifferent groups by evaluation at discharge. The first group consisted of 30 patients who under-went continued social rehabilitation (recovery group); the second group consisted of 25 patientswith discontinued social rehabilitation (the re-hospitalization group), and their demographicfactors were compared. The findings are summarized as follows: (i) the recovery group had a sig-nificantly shorter total hospitalization period and a smaller number of hospitalizations beforeentry into the facility, as compared to the re-hospitalization group; (ii) the recovery group wassignificantly better than the re-hospitalization group in terms of the score of ‘thought disorder’,although there was no difference in total Brief Psychiatric Rating Scale (BPRS) score, at thetime of entry into the facility; (iii) the recovery group was better than the re-hospitalizationgroup in terms of the Rehabilitation Evaluation Hall and Baker (REHAB) items ‘speech skills’and ‘self-care’ at the time of entry into the facility; (iv) the re-hospitalization group experiencedrelapse of symptoms, mainly positive ones, at the time of the discontinuation of the use of thefacility or re-admission. These findings suggest that to make good use of the support house,

the improvement of thought disturbance and self-care must be managed appropriately and theprolongation of hospital stay must be prevented before entry into the facility.

Key words hospitalization, rehabilitation, Recovery Scale (kaifuku scale), schizophrenia, self-care, supporthouse (engoryou), thought disorder.

INTRODUCTION

In recent years the importance of support for socialrehabilitation for mentally disabled persons has beenemphasized, and facilities and systems have been

established to meet the social demands. However, itremains unknown as to how to use various socialrehabilitation facilities to treat mentally disorderedpersons according to their mental disorders, mentalsymptoms, and recovery levels.

The purpose of the present, prospective study wasto attempt to clarify the characteristics of patientswho obtain good outcome by using the rehabilitationfacilities.

Since the Mental Health Act was amended in 1988,the establishment of various social rehabilitationfacilities has been promoted. Kijima Hospital, whichwe report in the present study, has a support house(engoryou) and a visiting vocational training facility.The users of the support house followed variablecourses; some of them were re-hospitalized due torelapse of mental symptoms. To facilitate the socialrehabilitation of mentally disabled persons, it is neces-sary to take appropriate support actions according tothe severity of disorder, and we thought that specifictarget and indices were necessary. To determine such

Correspondence address: Shinobu Sakiyama, Mie Mental HealthCenter, 2501-1, Myojin-cho, Hisai, Mie 514-1101, Japan. Email:[email protected]

Received 22 October 2001; revised 26 March 2002; accepted 8April 2002.

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610 S. Sakiyama etal .

target symptoms as indices, objective evaluation isnecessary. In the present study, mentally disabled per-sons who were discharged from the support housewere divided into two groups: a recovery group anda re-hospitalization group (definitions given in the

following section). The two groups were comparedin terms of demography and mental symptoms andrecovery ratings on various scales.

METHODS

Kijima Hospital is a private psychiatric hospital in theSenshu district, south of Osaka Prefecture. It has twooutside facilities: a support house and a visiting voca-tional training facility, which were opened in April1992. The vocational training facility is on the firstfloor and the support house occupies the second andthird floors.

Both the vocational training facility and thesupport house have a capacity of 20 persons. In thepresent study, the patients who were discharged fromthe support house between its opening and October1998 were studied for demography, outcome etc.

A total of 81 patients were discharged from thefacility during a 6.5-year period until 1 October 1998,of whom 55 with schizophrenia diagnosed using Diag-

nostic and Statistical Manual of Mental Disorders (3rdedition, revised; DSM-III-R) were the subjects in thepresent study.

A total of 35 men and 20 women was analyzed in

the present study. Their mean age at the time of entryinto the facility was 36.0 ± 12.3 years and their meanage at the time of first onset of the condition was24.9± 8.6 years. Duration of illness averaged 10.6± 8.7years, with a total hospitalization period of 4.6± 5.4years and a total number of hospitalizations of 3.3 ±

2.6. Stay at the support house averaged 15.0± 13.6months. Regarding other demographic factors,mean educational period was 11.5 ± 2.8years, and27% (n = 15) of the subjects stayed at facilities otherthan Kijima Hospital immediately before entering thefacility. Dose of medicine (haloperidol convert) when

entering the facility was 14.8±

12.4 mg.These subjects were divided into a recovery groupof 30 patients and a re-hospitalization group of 25patients and the two groups were compared in termsof demographic factors. The recovery group was de-fined as a group of patients who were able to live aloneor with their family, whereas the re-hospitalizationgroup was defined as a group of patients who werelater re-hospitalized due to difficulty in adaptation tostay in the support house. Mental symptoms were com-pared using Brief Psychiatric Rating Scale (BPRS)1,2

and Positive and Negative Symptom Scale (PANSS).3,4

Recovery of sociality was determined using Ozaki’srecovery scale5–8 and Rehabilitation Evaluation Halland Baker (REHAB;9,10 Japanese version11).

Mental symptoms were evaluated by the facility’sadvisor psychiatrist at the times of entry into and

discharge from the facility. Recovery of sociality wasevaluated on the basis of scores determined by thededicated staff involved in the daily care and voca-tional training for the patients, in consultation withthe facility’s advisor psychiatrist. Points were deter-mined as per the rating manuals supplied by thedevelopers of the respective scales. To avoid the per-sonal empathy of the evaluator and ensure objectiveevaluation, scoring was performed after discussionsamong two evaluators in different places of employ-ment (hospital psychiatrists and support house staff)who had been constantly involved in the course of care, from patient entry in the facility to follow up

following discharge from the facility.All data were statistically analyzed by the chi-

squared test and Mann–Whitney U -test. Here, Ozaki’srecovery scale5–8 is outlined. The scale was developedby Ozaki etal . to evaluate recovery of mentallydisabled persons from the viewpoint of interactionbetween the patient as a subject and the environmentas an object, and consists of 28 items. These items aredivided into four sets. For example, the set of itemsfor activeness in making a connection include ‘to livein one’s own way’ and ‘to attempt to transfer one’sown opinion and questions to others’. Each item is

scored in four grades (0–3), higher scores indicatingbetter findings.An evaluation manual is available.Themanual for evaluation had been received from anauthor of the scale.

A decision regarding the entry into the facilitywas made, irrespective of the source of referral,whether from Kijima Hospital or from another in-stitution, on the basis of medical consultation by apsychiatrist who served as an advisor for the sup-port house. Specifically, a patient proven to haveinsight, to accept treatment, and to wish to use thesocial rehabilitation facility was allowed to enter the

facility, in consideration of a comprehensive evalua-tion of the possibility of open management and grouplife. The extent of recovery from mental symptomswas determined after the facility entry decision wasmade.

RESULTS

As shown in Table 1, the total hospitalization periodwas significantly shorter for the recovery group thanfor the re-hospitalization group, and the total numberof hospitalizations was significantly smaller for the

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recovery group than for the re-hospitalization group.In terms of duration of illness, there was no significantdifference between the two groups.

Using BPRS, mental symptoms in the two groupswere evaluated in terms of clusters A through E andtotal score. As shown in Table2, at the time of entryinto the facility there was no significant difference intotal score between the two groups. By item, a signifi-cant difference was observed only in ‘thought distur-bance.’ At the time of discharge from the facility, therecovery group was significantly better than the re-hospitalization group in terms of ‘aenergia’, ‘thoughtdisturbance’, ‘excitement’ ‘hostility/suspiciousness’,and total score.

A PANSS-based evaluation (Table 3) revealed nosignificant difference between the two groups on anyscale at the time of entry into the facility. At the timeof discharge from the facility, the re-hospitalizationgroup had significantly higher points than did therecovery group in terms of positive scale and psy-chopathological scale.

The two groups were compared in terms of thera-peutic dose (calculated on the basis of haloperidol;Table 4). At the time of entry into the facility therewas no significant difference between the two groups.At the time of discharge from the facility, however,a significant difference was observed between therecovery group and the re-hospitalization group.

Effective use of the support house 611

Table2. Comparison on BPRS

Time at entry Time at dischargeRecovery Re-hospitalization Recovery Re-hospitalization

group (n=30) group (n=25) P group (n=30) group (n=25) P

A) Anxiety depressive mood 11.0±

3.3 9.4±

2.8 0.09 8.7±

3.0 9.9±

3.0 0.12B) Anergia 13.2±3.7 12.3±3.5 0.26 10.9±3.9 14.3±5.1 <0.05C) Thought disturbance 10.4±4.3 13.6±4.3 <0.05 9.2±4.1 15.9±5.4 <0.01D) Excitement 8.4±2.8 7.9±2.9 0.43 6.7±2.9 11.0±4.7 <0.01E) Hostility, suspicionsness 8.9±4.0 7.9±3.7 0.38 7.0±3.5 10.4±5.7 <0.05

Total 52.0±12.5 51.1±12.0 0.75 42.7±13.8 60.9±18.5 <0.01

BPRS, Brief Psychiatric Rating Scale.

Table1. Background of subjects

Recovery Re-hospitalizationgroup (n=30) group (n=25) P Total (n=55)

Age on entering the facility (years) 32.9±9.8 39.7±13.7 0.13 36.0±12.2

Duration of illness (months) 114.6±101.2 143.5±103.0 0.26 127.7±103.0Period of stay in rehabilitation facility (months) 16.4±14.0 13.3±12.6 0.44 15.0±13.5Total hospitalization period (months) 37.3±55.0 75.3±69.4 <0.01 54.6±64.8Total no. hospitalizations 2.6±2.2 4.2±2.8 <0.01 3.3±2.6

Table3. Comparison on PANSS

Time at entry Time at discharge

Recovery Re-hospitalization Recovery Re-hospitalizationgroup (n=24) group (n=19) P group (n=24) group (n=19) P

Positive symptom scale 23.5±9.3 23±10.3 0.9 18.5±6.5 29.2±12.3 <0.01Negative symptom scale 63.5±35.0 54.7±33.7 0.44 48.5±28.4 64.6±40.3 0.13Composite scale -40.1±28.2 -31.7±28.7 0.33 -30.0±22.9 -35.4±34.8 0.79Psychopathological scale 63.5±12.1 56.8±13.5 0.08 51.2±16.8 71.4±12.0 <0.01

PANSS, Positive and Negative Symptom Scale.

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Subsequently, another evaluation was conductedusing the recovery scale. As shown in Table 5, nosignificant difference was observed between the twogroups in any set of items at the time of entry in thefacility. At the time of discharge from the facility, therecovery group had significantly better (higher) pointsthan the re-hospitalization group in all items.

A REHAB-based evaluation of social functionswas also conducted (Table 6). Lower scores indicatebetter results. As shown in the Table, at the time of entry into the facility, the recovery group was sig-nificantly better than the re-hospitalization group interms of ‘speech skills’, which pertains to the qualityof speech, and ‘self-care.’ As for disturbed speech con-

cerning the quantity of speech, there was no signifi-cant difference between the two groups. At the timeof discharge from the facility, the recovery group hadsignificantly better (lower) points than the othergroup for all sets of items.

DISCUSSION

Social rehabilitation facilities, including the supporthouse dealt with in the present study, are intended forovercoming disability and mitigating handicap formentally disabled persons. To ensure therapeuticand reasonable management of the facilities, variousaspects of the user must be evaluated as objectively as

Table4. Dose of medicine (converting haloperidol)

Time at entry Time at dischargeRecovery group Re-hospitalization Recovery group Re-hospitalization

(n=30) group (n=25) P (n=30) group (n=25) P

Dose of medicine (mg) 14.1±13.0 15.7±11.8 0.33 13.9±18.3 19.1±15.0 <0.05

Table5. Comparison on recovery scale



Activeness in making a 10.5±5.9 7.6±5.9 0.07 14.6±7.8 5.7±4.8 <0.01relation to other

Consideration of 3.7±2.2 3.4±2.2 0.45 5.1±2.6 2.5±2.0 <0.01

external appearanceExtent of social 4.8±3.2 3.6±2.3 0.17 7.6±4.9 2.8±2.1 <0.05involvement

Flexibility in making 11.7±6.2 8.6±7.1 0.06 15.3±8.6 5.5±5.5 <0.01a connection

Total score 30.7±15.8 23.3±15.9 0.07 42.6±22.8 17.0±11.6 <0.01

Table6. Comparison on REHAB



Social activity 33.3±10.9 32.4±11.2 0.61 27.7±13.1 39.6±10.3 <0.01Speech skills 8.1±4.3 10.8±4.4 < 0.05 7.1±4.6 13.1±4.7 <0.01Disturbed speech 10.9±5.7 9.5±5.2 0.57 8.7±4.8 12.2±5.2 <0.05Self-care 21.3±9.3 28.1±10.4 < 0.05 19.7±10.3 33.4±8.2 <0.01Community skills 10.5±3.5 12.3±3.8 0.08 8.8±4.4 14.5±3.3 <0.01Total (1+3+4+5) 80.0±26.6 89.8±28.5 0.09 68.6±32.5 108.2±22.6 <0.01

REHAB, Rehabilitation Evaluation Hall and Baker.

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possible to clarify patient characteristics on whichgeneral treatment and stay at the facility are effectiveand to provide feedback to the actual setting. Withthis in mind, the present study was conducted. Itappeared important to not only have an evaluation of

impairment, but also to have an evaluation of dis-turbance of daily living classified by Murata12 under(i) disturbance of basic living skills; (ii) disturbanceof personal relations ability; and (iii) disturbance of work ability. In other words, mental symptoms andrecovery of sociality were considered to be importantand were evaluated using the scales described here.

The difference between the recovery group and there-hospitalization group observed at the time of entryinto the facility has the potential for the predictionof prognosis. This difference also appears to be of major significance in preventing patient pain. In otherwords, the inappropriate use of a facility not fitting to

the severity and recovery of mental symptoms candamage patient condition, which in turn can cause therelapse of symptoms and social withdrawal, as sug-gested from the fact that the PANSS-based evaluationat the time of discharge from the facility revealed asignificant difference in positive symptoms betweenthe re-hospitalization group and the recovery group,and from the results of the comparison of BPRSratings for the two groups at the time of dischargefrom the facility. The significant difference in the doseof drug observed at the time of discharge from thefacility also appears to reflect mental symptoms.

Kupper and Hoffman reported that there was asubgroup of patients who had reduced global im-provement ratings in an evaluation on the Nurses’Observation Scale for Inpatient Evaluation (NOSIE)after initiation of vocational rehabilitation.13,14

In the present study, the independency of the evalu-ation could not be achieved, nevertheless scoringwas devised to avoid the personal empathy of theevaluator and ensure objective evaluation. This lackshould be considered as a limit of the present study,but comparison of the recovery group and the re-hospitalization group at the time of entry into the

facility revealed a significant difference in scores of ‘thought disturbance’, ‘self-care’, and ‘total number of hospitalizations’.

Thought disorder

In terms of BPRS ratings, the recovery group was sig-nificantly milder than the re-hospitalization group interms of ‘thought disturbance’. This finding is consis-tent with a report of Racenstein etal . and with thesuggestion by Harrow and Marengo that ‘thought dis-order’ can serve as a predictive factor for outcomes

such as sociality.15,16 In terms of REHAB ratings atthe time of entry into the facility, the recovery groupwas significantly better than the re-hospitalizationgroup in terms of the set of items ‘speech skills’. The‘speech skills’ set of items consists of ‘meaning of

words’ and ‘clearness of words’, which relate to thequality of speech. In contrast, in terms of the set of items ‘disturbed speech’, which concerns the quantityof speech, no significant difference was observedbetween the two groups. These results demonstratethat the two groups differed from each other in termsof the ability to have verbal communication with clearwords, rather than the quantity of speech and thenumber of spontaneously uttered words. This appearsto be associated with the significant difference in theBPRS rating of ‘thought disturbance’ at the time of entry into the facility between the two groups. Thisis consistent with the conclusion of Norman et al.

that disorganization is the most reliable predictorof several aspects of community functioning.17

It can be said therefore that patients with mild‘thought disorder’ who are able to speak clear andmeaningful words have the greater potential formaking use of the support house. In this context, itappears necessary to provide pharmacotherapy etc.focusing on ‘thought disorder’ from the time of hospi-tal admission, to encourage and train the patientto have meaningful verbal communication, and tocontinue to take such actions even after hospitaldischarge and initiation of the use of a social reha-

bilitation facility. For example, social skill training(SST), becoming popular, appears to be effective.

Self-care

A REHAB-based evaluation at the time of entry intothe facility revealed that the recovery group wassignificantly better than the re-hospitalization groupin terms of ‘self-care’. The ‘self-care’ items consistedof ‘manner of eating meals’, ‘making an appearance’,‘dressing’, ‘arrangement of belongings’, and ‘advisorysupport’. This finding suggests that the extent of ‘self-

care’ may be predictive of the restoration to socialactivities. In other words, patients capable of consider-ing ‘self-care’ are thought of as able to behave as amember of a population bearing in mind the time andplace, rather than as complacent. In short, the capabil-ity of considering ‘self-care’ may be viewed as theminimum essential ability to maintain personal rela-tionships for a normal social life. Clean appearanceand dressing and appropriate make-up are suggestedto determine such ability and to provide indices forthe prediction of outcome for social rehabilitation. Itseems very likely that encouragement and guidance


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regarding consideration of ‘self-care’ starting duringhospitalization before entry into an intermediatefacility will contribute to the restoration of the patientto social activities.

Total hospitalization period

In the present study, the total hospitalization periodbefore entry into the facility was significantly shorterfor the recovery group than for the re-hospitalizationgroup. Similarly, the total number of hospitalizationsbefore entry into the facility was significantly smallerfor the recovery group. This finding is generally con-sistent with a report of Wakutsu etal .18 In terms of duration of illness, there was no significant differencebetween the two groups. Bearing in mind that recov-erability was not associated with duration of illnessbut with the hospitalization period, we hypothesize as

follows. Hospitalism may have an effect, caused bythe fact that psychiatric hospitals generally representa socially isolated, closed, protective environment. Inother words, the re-hospitalization group may repre-sent a population of patients suffering from some(iatrogenic) damage due to prolonged hospitalization,during which they are isolated from common society,lose various skills for social life, or miss the chances of (re)acquirement of various skills. The skills for sociallife are thought of as involving personal communi-cation for SST etc. and making a good appearanceand other forms of behavior, to thought of generally

accepted social ideas such as ‘obviousness’. Thesefindings are consistent with the report by Ciompi.19

On the basis of these findings it is hypothesizedthat in chronic schizophrenia as well, social rehabilita-tion support activities must be commenced as early aspossible20 and individually and deliberately, and it issuggested that a hospitalization environment and atherapeutic plan considering the social rehabilitationfor patients be implemented. For this purpose, asshown through the present study, the improvement of ‘thought disorder’ and ‘self-care’ must be emphasized.For example, as stated by Spaulding etal ., treatment

focusing on the improvement of cognitive functionand evaluation based on assessment of interpersonalproblem-solving skills (AIPSS) etc. may be useful.21–23

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