動機再促進團體方案應用於慢性思覺失調症患者之成效

Abstract

背景及目的： 動機缺損為思覺失調症患者常見的臨床問題，多篇文獻證實其為影響患者生活功能、目標導向行為與失能之關鍵，因此動機問題為思覺失調症患者復健之路上重要議題。動機再促進過程(remotivation process)源自人類職能模式的概念，專為動機低落之個案設計動機促進的介入策略。已有文獻使用此策略於一系列共八次動機再促進團體介入並運用於急性思覺失調症患者。而慢性思覺失調症患者經常出現參與日常活動動機低落之情形。因此本研究目的為驗證動機再促進團體介入運用於慢性思覺失調症患者之成效。 研究方法： 本研究收錄30名慢性思覺失調症或情感型思覺失調症患者，男女各15位、平均年齡為50.33歲，皆為台灣北部某精神專科醫院慢性病房住院病人，研究使用準實驗(quasi-experimental)單盲設計，16位參與者分配至實驗組另外14位為控制組，執行前測後實驗組進行四週共八次動機再促進團體方案，控制組則為四週常規治療，介入後兩週內進行後測。 研究主要成效指標為意志量表(volitional questionnaire)與次要成效指標包含生活品質、症狀與情緒變化，以及收集參與者對動機再促進團體方案之滿意度及質性回饋。 資料分析以卡方檢定及獨立T檢定比較兩組人口學變項及前測分數之差異。再使用線性混合模式(linear mixed-effects model)分析兩組前後測各變項之差異，以驗證動機再促進團體介入之成效。 結果： 經線性混合模式分析結果指出，兩組參與者意志變化程度無組別及時間顯著交互作用，但時間主效果顯著影響，進一步使用獨立T檢定與配對T檢定分析，發現兩組後測時意志量表分數皆顯著高於前測分數，然而組間變化量無顯著差異，表示兩組參與者後測時意志層級皆提升。台大症狀量表、簡式症狀量表、生活品質量表與個案自陳成效測量資訊系統-情緒相關量表-簡短版分數不論兩組間、前後測及組別與時間交互作用皆無顯著差異，然而進一步分析發現控制組後測時焦慮與憂鬱程度顯著高於前測，但實驗組之焦慮及憂鬱症狀無明顯改變。另經獨立T檢定分析發現，兩組間各變項前後測變化量僅憂鬱程度有差異其餘則無，實驗組後測時憂鬱程度下降，而控制組則上升。 動機再促進方案參與者完成率為100%、平均出席率92.19%、對活動滿意度平均4.38分(滿分5分)，質性觀察發現方案參與者之活動參與主動性及人際互動提升。 結論： 動機再促進方案用於慢性思覺失調症患者有高度適用性，且對意志層級之提升、憂鬱與焦慮情緒之穩定有一定成效，然而對生活品質、症狀之影響不顯著。

Background: Motivational deficits are common problems for persons with schizophrenia. Recent research identified that the lack of motivation would affect global and social function, decrease goal-directed behaviors and participation of occupations of patients with schizophrenia. Therefore, it is an important issue to enhance the motivational status of persons with schizophrenia. We adapted strategies and principles suggested by remotivation process which was developed based on the model of human occupation. The researcher has examined the effect of an 8-session treatment program on a group of persons with acute schizophrenia. We modified from the previous program and developed our own one focusing on activities and case management. Therefore, the purposes of the study is to investigate the efficacy of the newly developed remotivation program on a group of persons with chronic schizophrenia. Method: The subjects were recruited from a large psychiatric institute. Upon meeting the subjects’ criteria, the subjects were invited to participate in the study and signed the informed consent form of the study (approved by institutional IRB board). Since the study is quasi-experimental design, the subjects were assigned to experimental and control groups based on convenience. There were 16 and 14 subjects attending the experimental and control groups. The experimental group received 2 treatment session per week for 4 weeks. The control group received routine treatment. The average age is 50.33 years old. There are 15 males and 15 females in them. All participants completed pre-test before intervention and post testing after experiment ends within a week. The therapists who scored the volitional questionnaire were blind to the group assignment. The primary outcome of the study was assessed by volition questionnaire. The secondary outcomes included the quality of life, symptoms severity and emotion related status. We also collected subjects’ feedback using questionnaire. Chi-square and independent t-test were used to analyze demographic and baseline scores. The linear mixed-effects model was applied to examine the efficacy of the proposed program. Results: The results of the study showed that the improvement of the volitional status of the subjects in both groups were significant. The degree of anxiety and depression in the control group significantly increased after treatment, but they remained stable for the experimental group. There was significant improvement in the depression of the subjects in the experiment group than those in the control group. The results of the feedback questionnaire showed that subjects attending experimental group felt positive about the program and engaged in the interactive group activities increasingly. Conclusions: Our newly developed remotivation program does produce positive effect on reducing level of depression and enhancing volitional status of the participants. The subjects in the control group also demonstrated significant improvement of volitional status after the treatment which provides evidence of the general OT program. The program is feasible and welcomed by the participants. The limitations of the study include small sample size, non-experimental design and single blind design. We suggested that the program can be modified to include more case management component to fit the individualized needs. We also suggested that a larger sample size can be implemented in the future study.