應用改良式動機再促進方案於社區思覺失調症患者之成效

Abstract

研究背景及目的 思覺失調症患者常見動機缺損的問題且隨著病程演進，長期影響個體從事職能或參與日常生活，包含自我照顧、工作表現及人際關係，甚至面臨個人及社會層面的阻礙，不僅影響其社會參與，也可能導致較差的功能結果，尤其以社區的思覺失調症患者影響最為廣泛，以致難以在社區中獨立生活。以人類職能模式為基礎的動機再促進過程是一種職能治療介入手法，主要改善患者的意志次系統及動機缺失問題，國內已有學者將此方案應用於急性及慢性患者，並根據動機再促進策略，發展適用於臨床的介入方案，故本研究目的為應用改良式動機再促進方案於社區型思覺失調症患者之成效。 研究方法 本次研究於台灣北部某精神專科醫院執行，招募對象為某社區復健中心之個案，共招募38名思覺失調症患者，受試者收案標準有三: (1)經精神專科醫師依精神疾病診斷手冊第四版(DSM-Ⅳ)或ICD-10診斷為思覺失調症(schizophrenia)或情感思覺失調症(schizoaffective disorder)之個案。(2)年齡大於18歲者。(3)同意參與本研究並簽署受試者同意書者。受試者排除標準有二: (1)神經性疾病或嚴重腦傷者。(2) 合併物質濫用或成癮障礙者。由電腦將個案隨機分派為實驗組20名及控制組18名，實驗組接受每周兩次，每次五十分鐘，共八次的動機再促進團體方案，且於團體結束後填寫活動滿意度調查及活動表現自評表，控制組僅接受常規治療。介入前後兩組皆須完成意志量表(VQ)、精神病患社會功能量表(SFST)、溝通與互動技巧評估工具中文版(ACIS-C)及台大症狀量表(TSCL)。本實驗為隨機分派、單盲設計，評估者不知其分組。統計分析採用成對樣本t檢定(Paired Sample t test)比較介入後兩組內各變項之差異；以無母數統計分析（nonparametric test）曼-惠特尼檢定(Mann-Whitney U test)及獨立樣本t檢定(Independent Sample t test)比較介入後兩組間各變項之差異。為進一步確認介入療效，以兩組間各項測驗分數之效應值(effect size)，比較各變項之效果量，效應值大於0.8為高效果量；0.5至0.8為中度效果量；0.2至0.5為低效果量。 結果 本研究共納入38位受試者資料，實驗組20位，控制組18位。實驗組經過四周、共八次的改良式動機再促進方案介入，以Mann-Whitney U test (p=0.04)及獨立樣本t檢定(p=0.01)檢驗兩組間前後測變化量，結果顯示，實驗組相較於控制組能有效改善患者動機缺失問題，效應值( Cohen's d=0.74)屬中度效果量。然而，其他成效指標包含:精神病患社會功能量表、溝通及互動技巧量表及台大症狀量表結果顯示實驗組及控制組兩組並無明顯差異。 實驗組平均出席率100%、平均活動滿意度4.12-4.43、平均表現自評分數4.12-4.25，顯示改良式動機再促進方案有良好的活動參與度、活動滿意度及個人表現滿意度。臨床回饋及觀察則發現，實驗組個案對於改良式動機再促進方案感到較高的興趣及參與感、對於課程有較多期待、同時對於課程執行及安排方式感到較為滿意。 結論 於社區接受精神復健的思覺失調症患者雖然大多屬精神症狀穩定，然而普遍卻忽略了負性症狀所造成的影響，尤其以動機缺失的影響更為廣泛。本次研究結果顯示，此介入方案可以有效改善動機問題，故建議未來臨床實務上能夠加以運用，提供社區精神醫療以個案為中心且多元的介入方案。

Background Patients with schizophrenia often experience deficits in motivation, which can significantly impact their functional abilities and participation in daily life activities as the illness progresses. These deficits affect self-care, work performance, interpersonal relationships, and may lead to personal and societal barriers. This not only diminishes their social engagement but also results in poor functional outcomes, particularly affecting community-dwelling individuals with schizophrenia. Motivational deficit is a key concern in the treatment and rehabilitation of schizophrenia. The remotivational program, based on the Model Of Human Occupation , is a therapeutic intervention aimed at improving the volition subsystem and addressing motivational deficit in patients. Scholars domestically have applied this approach to both acute and chronic patients with schizophrenia, developing clinical intervention based on remotivational program strategies. Therefore, this study aims to assess the effectiveness of an adapted remotivational process in community-dwelling patients with schizophrenia. Methods This study is conducted at a psychiatric specialty hospital in northern Taiwan and recruits participants from a community rehabilitation center. This study included a total of 38 participants, diagnosed with schizophrenia or schizoaffective disorder, adhering to the following inclusion criteria: (1) Cases diagnosed with schizophrenia or schizoaffective disorder by a psychiatric specialist according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) or ICD-10, (2) aged 18 years or older, and (3) willingness to participate in the research and signing of the informed consent form. Exclusion criteria include: (1) neurological disorders or severe brain injury, and (2) concurrent substance abuse or addiction disorders. Participants are randomly assigned by computer into two groups: with 20 in the experimental group and 18 in the control group. The experimental group receives a modified remotivational program twice a week for 50 minutes per session over eight sessions. After completing the group sessions, participants fill out satisfaction surveys and self-assessment performance forms. The control group receives standard treatment only. Both groups complete pre and post assessments, which include the Volitional Questionnaire (VQ), the Social Functioning Scsle-Taiwan short version (SFST), the Assessment of Communication and Interaction Skills-Chinese version (ACIS-C), and Taita symptom checklist (TSCL). This experiment employs a randomized assignment and single-blind design, with assessors unaware of group assignments. Statistical analysis uses the paired sample t-test to compare the differences in each variable within the two groups after the intervention. Additionally, nonparametric tests, specifically the Mann-Whitney U test, and the independent sample t-test are employed to compare the differences in each variable between the two groups post-intervention. To further confirm the efficacy of the intervention, the effect size of each test score between the two groups is calculated to compare the magnitude of effects. An effect size greater than 0.8 is considered high; 0.5 to 0.8 is considered moderate; and 0.2 to 0.5 is considered low. Result This study included data from 38 participants, with 20 in the experimental group and 18 in the control group. The experimental group underwent a four-week intervention of a modified remotivational program consisting of eight sessions. Changes between pre- and post-tests were assessed using the Mann-Whitney U test (p=0.04) and independent samples t-test (p=0.01). The results indicated that the experimental group significantly improved motivation issues compared to the control group, with an effect size (Cohen's d=0.74) indicating a moderate effect. However, other outcome measures including the Social Functioning Scsle-Taiwan short version (SFST), the Assessment of Communication and Interaction Skills-Chinese version (ACIS-C), and Taita symptom checklist (TSCL) showed no significant differences between the experimental and control groups. The experimental group had an average attendance rate of 100%, average activity satisfaction scores ranging from 4.12 to 4.43, and average self-assessment scores ranging from 4.12 to 4.25. These results indicate high levels of participation, satisfaction with the activities, and personal performance satisfaction for the improved motivational enhancement program. Clinical feedback and observations revealed that participants in the experimental group showed higher interest and engagement in the program, had greater expectations for the course, and expressed higher satisfaction with the course implementation and organization. Conclusion While individuals with schizophrenia undergoing community-based mental rehabilitation generally exhibit stable psychiatric symptoms, they often overlook the pervasive impact of negative symptoms, particularly the widespread influence of motivational deficits. This study's findings demonstrate that the intervention program effectively addresses motivational issues. Therefore, it is recommended that future clinical practices integrate and utilize such interventions to provide community-based psychiatric care with individualized and diverse intervention strategies.