Life skills programmes for chronic mental illnesses: Cochrane systematic review

Abstract

Assessed as up to date: 2010/06/20

Background

Most people with schizophrenia have a cyclical pattern of illness characterised by remission and relapses. The illness can reduce the ability of self-care and functioning and can lead to the illness becoming disabling. Life skills programmes, emphasising the needs associated with independent functioning, are often a part of the rehabilitation process. These programmes have been developed to enhance independent living and quality of life for people with schizophrenia.

Objectives

To review the effects of life skills programmes compared with standard care or other comparable therapies for people with chronic mental health problems.

Search methods

We searched the Cochrane Schizophrenia Group Trials Register (June 2010). We supplemented this process with handsearching and scrutiny of references. We inspected references of all included studies for further trials.

Selection criteria

We included all relevant randomised or quasi-randomised controlled trials for life skills programmes versus other comparable therapies or standard care involving people with serious mental illnesses.

Data collection and analysis

We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis, based on a random-effects model. For continuous data, we calculated mean differences (MD), again based on a random-effects model.

Main results

We included seven randomised controlled trials with a total of 483 participants. These evaluated life skills programmes versus standard care, or support group. We found no significant difference in life skills performance between people given life skills training and standard care (1 RCT, n = 32, MD -1.10; 95% CI -7.82 to 5.62). Life skills training did not improve or worsen study retention (5 RCTs, n = 345, RR 1.16; 95% CI 0.40 to 3.36). We found no significant difference in PANSS positive, negative or total scores between life skills intervention and standard care. We found quality of life scores to be equivocal between participants given life skills training (1 RCT, n = 32, MD -0.02; 95% CI -0.07 to 0.03) and standard care. Life skills compared with support groups also did not reveal any significant differences in PANSS scores, quality of life, or social performance skills (1 RCT, n = 158, MD -0.90; 95% CI -3.39 to 1.59).

Authors' conclusions

Currently there is no good evidence to suggest life skills programmes are effective for people with chronic mental illnesses. More robust data are needed from studies that are adequately powered to determine whether life skills training is beneficial for people with chronic mental health problems.

Author(s)

Tungpunkom Patraporn, Maayan Nicola, Soares-Weiser Karla

Summary

Life skills programmes for chronic mental illnesses

Having a mental health problem can cause difficulties and obstacles in all areas of life, even those as simple as washing, shopping, talking openly with other people, brushing teeth, cleaning the house, managing money, making friends, shaving and being independent. Having a mental health problem, combined with the sleep-like haze of many antipsychotic medications, limits people’s ability to look after themselves, socialise with other people, take part in education or career development and find work. 

Life skills programmes attempt to remedy some of these difficulties by encouraging independent living, so enhancing quality of life. Life skills often have several components: communication and talking; financial awareness and money management; domestic tasks (such as cooking, washing- up dishes, hoovering, doing the laundry and running a home); and personal self-care (such as washing, bathing, cleaning teeth, shaving, combing hair and getting dressed). Other life skills include training on coping with stress, shopping for and eating healthy food, knowing the time, taking medication, improving social skills, using transport and forward planning.  

Rehabilitation or getting better is slow, complex and difficult. There are many ways of engaging with people during this process, including: creative therapies (art, drama, music, poetry, education, dancing, singing); life skills (as described above); work-based therapy to enhance employment; and recreational activities (such as group walks, swimming, sport, reading, writing a diary, watching television, going to parties, events and day trips). 

This review looks at different types of rehabilitation therapy for people with mental health problems. It compares life skills training with occupational therapy and peer support (where a group of people with mental health problems were encouraged to help each other). Comparison was also made with standard or usual care. Life skills, occupational therapy and peer support all aim to promote health by enabling people to perform meaningful and purposeful activities.

In the main, the authors of the review conclude that there is no great difference between those that receive life skills, occupational therapy, peer support and standard care. It is questionable if people should be put under pressure to attend life skills and not known whether life skills are a benefit or perhaps even harmful. Professionals and service users invest much time in life skills and this may cost both time and money. However, the quality of scientific evidence is low and uncertain. The authors note that life skills are still a simple and easy way that has the potential to make great benefits for people who are almost disabled by mental health problems.

This plain language summary has been prepared by Ben Gray of Rethink Mental Illness: Benjamin Gray, Service User and Service User Expert, Rethink Mental Illness. Email: ben.gray@rethink.org

Reviewer's Conclusions

Implications for practice

Despite the addition of three studies to this review, the quality of the reporting in these studies is very low and they do not address any additional outcomes that were missing from the previous version of this review. The overall conclusions of this review therefore remain unchanged.

1. People with serious mental illness:

Considering that there is severely limited evidence that life skills training programmes are of value to those with serious mental illnesses, their advocates would be well justified in calling for a randomised controlled trial in this area. Until such time as any evidence of benefit is available, it is questionable whether recipients of care should be put under pressure to attend such programmes.

2. Clinicians:

Many healthcare professionals spend significant parts of their jobs training people with chronic mental health problems in the area of life skills. This review shows that there is no evidence indicating that such programmes are helpful or harmful to this vulnerable group. The healthcare profession is responsible for a situation where an almost unevaluated and possibly expensive treatment is provided for a vulnerable population.

3. Managers/policy makers:

It is likely that short-sighted managers or policy makers would see life skills programmes as ripe for closure. Nevertheless, others may see this as an ideal opportunity for evaluation and give full support to those wishing to undertake such work.

Implications for research

1. General:

There is a need for programmes tailored to improve the quality of life of people with chronic mental illnesses. From the limited data available, life skills appears to provide no benefit for people with chronic mental health problems; however, the data for the outcomes reported in this review were under-powered and unlikely to detect a real treatment effect. If there are benefits to be gained from life skills then larger trials of adequate power are needed to determine its value for such people. Large randomised controlled trials are needed to investigate the effects of life skills programmes. We are well aware that undertaking such a trials needs painstaking planning and that our suggestions are just those of reviewers in this area. However, we have considered the relevant trials in some detail and have learnt from their strengths and weaknesses. An outline for a suggested design of study is reported in Suggested design of study.

2. Specific:

2.1 Randomisation and blinding

If readers are to be assured that selection bias has been eliminated then the process of randomisation should be clearly described. Blinding in this area is problematic if the assessor is also implementing the intervention, as would appear to be the case. We feel it would be possible to design a study with simple pragmatic and objective outcomes that could be recorded by those not so closely involved in the intervention under evaluation.

2.2 Outcomes

Scale data, when derived from validated scales, are difficult to interpret, but it is impossible to decipher with any confidence data produced by a non-validated scale. We would suggest that if a trial is to be of use, dichotomous data are most valuable to both the clinician and recipient of care. These data should relate to the desired life skills as well as mental state, satisfaction and costs. If scale data are to be used, the interpretation of the results would be enhanced if future trials made use of the same scales used in this review, which would enable us to pool the outcome data.

2.3 Reporting of data

Clear presentation of raw dichotomous data assists reviews such as this. If continuous data are to be used they should be presented with a mean, SD and the total numbers from which they were derived. Inexact P values are unhelpful.

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