Occupational therapy interventions for Schizophrenia: A systematic review

M. Mahendran¹*, S.M Surya², Athulya K Anil³, Thiraviam Pillai⁴, Suhail Shagul Hameed⁵

¹Consultant paediatric occupational therapist, Hamsa rehab for kids, unit of Kauvery hospital

²Ph. D, Research Scholar, The Gandhigram Rural Institute-Deemed to be University Dindigul

^3,4,5Clinical posting student, Department of Occupational Therapy, Hamsa rehab centre, unit of Kauvery hospital

*Correspondence mail ID: [email protected]

Abstract

Schizophrenia significantly impairs individuals’ cognitive, social, and occupational functioning, making its management a multidisciplinary challenge. Occupational therapy (OT) interventions address functional limitations and promote independence, yet the breadth of evidence supporting specific approaches remains unclear. This systematic review evaluates the effectiveness of OT interventions for schizophrenia. Databases including PubMed, Psyc INFO, and Scopus were searched for peer-reviewed studies published between 2010 and 2024. Inclusion criteria were randomized controlled trials (RCTs), quasi-experimental studies, and systematic reviews focusing on OT-specific interventions for schizophrenia. A total of 20 studies were included. Key interventions included cognitive remediation, social skills training, and activity-based therapies. Findings highlight significant improvements in social functioning, executive functioning, and quality of life. However, heterogeneity in intervention designs and outcome measures limits generalizability. Future research should standardize protocols to establish evidence-based practices.

Keywords: Occupational Therapy, Evidence based practice, Schizophrenia, Systematic Review.

Introduction

Schizophrenia is a chronic and severe psychiatric disorder affecting approximately 1% of the global population. It is characterized by a complex interplay of symptoms that significantly disrupt an individual’s cognitive, emotional, and social functioning. The disorder presents with a spectrum of symptoms broadly categorized into positive symptoms (hallucinations, delusions), negative symptoms (apathy, emotional blunting, withdrawal), and cognitive deficits (impaired memory, attention, and executive functioning). Together, these symptoms profoundly affect an individual’s quality of life, limiting their ability to engage in meaningful daily activities and vocational pursuits.

Pharmacological treatments, primarily antipsychotics, are considered the first line of intervention for schizophrenia. While effective in managing positive symptoms, they have limited impact on negative symptoms and cognitive impairments, which often lead to persistent functional deficits. These challenges underscore the need for comprehensive rehabilitative strategies that go beyond symptom control to address broader aspects of functioning. Among these, Occupational Therapy (OT) has emerged as a vital approach, aiming to enhance an individual’s ability to perform daily activities and improve their overall quality of life.

This systematic review explores the role, effectiveness, and evidence supporting OT interventions in schizophrenia, focusing on cognitive remediation, social skills training, and purposeful activities. It aims to synthesize current research to identify best practices in OT for this population.

Understanding Schizophrenia’s Impact on Functioning

Schizophrenia affects multiple domains of functioning, necessitating a multifaceted approach to care:

Cognitive Deficits: Cognitive impairments are a core feature of schizophrenia, impacting memory, attention, processing speed, and executive functioning. These deficits often predict long-term outcomes, such as employment status and social integration, more strongly than positive or negative symptoms.

Negative Symptoms: Negative symptoms like apathy, anhedonia, and social withdrawal contribute to significant functional impairments. Unlike positive symptoms, they are less responsive to pharmacological treatments, making rehabilitative interventions critical.

Social and Vocational Challenges: Schizophrenia often disrupts social relationships, vocational activities, and community participation. Individuals may struggle to maintain employment or develop meaningful relationships, further compounding isolation and stigma. Given these challenges, OT aims to bridge the gap between symptom reduction and functional recovery by focusing on skills that support independence and engagement in meaningful roles.

Occupational Therapy: Principles and Approaches

OT in schizophrenia is rooted in the principle of enabling individuals to participate in meaningful activities that promote health and well-being. Key approaches include:

Cognitive Remediation Therapy (CRT): CRT focuses on improving cognitive functions like attention, memory, and problem-solving. Techniques such as computer-based training programs, errorless learning, and metacognitive strategies are commonly used.

Social Skills Training (SST): SST targets interpersonal skills, teaching individuals to navigate social situations effectively. Role-playing, feedback sessions, and group interactions are integral components of this intervention.

Engagement in Purposeful Activities: OT emphasizes the importance of engaging individuals in activities that align with their interests and goals, such as vocational training, leisure activities, and self-care routines.

Environmental Modifications: OT practitioners assess and adapt the individual’s living or working environment to reduce barriers and enhance participation.

Psychoeducation and Family Involvement: Educating individuals and their families about schizophrenia and its management fosters a supportive network that promotes recovery.

Evidence Supporting Occupational Therapy in Schizophrenia

Several studies have investigated the effectiveness of OT interventions in improving functional outcomes for individuals with schizophrenia.

Cognitive Remediation: Meta-analyses have demonstrated that CRT can significantly improve cognitive functioning, with moderate effects on social and occupational outcomes. Combining CRT with other interventions, such as SST, enhances its impact.

Social Skills Training: SST has been shown to improve communication skills, reduce social anxiety, and enhance social integration. Group-based SST is particularly effective in fostering peer support and motivation.

Vocational Rehabilitation: OT interventions that incorporate supported employment models have yielded positive outcomes, with higher rates of job placement and retention compared to traditional approaches.

Quality of Life Improvements

Engaging individuals in meaningful activities has been linked to improvements in self-esteem, autonomy, and overall quality of life. Structured programs, such as gardening, art therapy, and sports, are widely appreciated by participants.

Integrated Care Models

Combining OT with other therapeutic modalities, such as psychotherapy and pharmacotherapy, has shown promise in addressing the multifaceted needs of individuals with schizophrenia. Despite these positive findings, challenges remain. The effectiveness of OT interventions varies depending on factors such as the individual’s symptom severity, motivation, and support system. Additionally, there is a need for standardized protocols to guide OT practice in schizophrenia.

Challenges in Occupational Therapy for Schizophrenia

Individual Variability

Schizophrenia manifests differently across individuals, requiring highly personalized intervention plans. Tailoring OT interventions to meet diverse needs can be resource-intensive.

Stigma and Accessibility: Stigma surrounding mental illness often limits individuals’ willingness to seek therapy. Moreover, access to OT services may be restricted in low-resource settings.

Measurement of Outcomes: Evaluating the effectiveness of OT interventions is challenging due to the subjective nature of functional outcomes and the lack of standardized assessment tools.

Integration with Other Services: Coordinating OT with other healthcare services requires robust communication and collaboration, which may be lacking in fragmented healthcare systems.

Methodology

Search Strategy: A systematic search was conducted in PubMed, PsycINFO, and Scopus for studies published between 2009 and 2024. Keywords included “occupational therapy,” “schizophrenia,” “cognitive remediation,” “social skills training,” and “functional recovery.”

Inclusion Criteria

Peer-reviewed studies focusing on OT interventions for schizophrenia.
Study designs including RCTs and systematic reviews.
Studies reporting functional, cognitive, or quality of life outcomes.

Exclusion Criteria

Studies without a clear focus on OT.
Non-English publications.
Case studies or expert opinions.

Data Extraction and Analysis

Key data (e.g., sample size, interventions, outcomes) were extracted using a standardized template. Study quality was assessed using the Cochrane Risk of Bias Tool.

Fig (1): Year-wise classification of the occupational therapy- systematic based

Treatment Methods	RCT	Systematic Review	Percentage (%)
Cognitive Remediation	17	3	20
Social Skill Training	8	6	14
Engage in Purposeful Activities	0	0	0
Environmental Modification	0	1	1
Vocational Rehabilitation	16	2	18
Quality of Life Improvement	21	8	29
Integrated Care Model	1	0	1

Study Characteristics

Twenty studies met the inclusion criteria, with sample sizes ranging from 30 to 200 participants. Interventions were primarily delivered in outpatient settings over 8–24 weeks. Key Interventions and Outcomes.

Cognitive Remediation: Six studies reported significant improvements in executive functioning and working memory.
Social Skills Training: Five studies demonstrated enhanced social interactions and reduced social withdrawal.
Activity-Based Therapies: Nine studies highlighted improved occupational engagement and quality of life.

Overall Findings: While most studies reported positive outcomes, heterogeneity in intervention types and outcome measures hindered meta-analytic comparisons.

Discussion

This review underscores the potential of OT in addressing schizophrenia’s functional impairments. Cognitive remediation and social skills training emerged as evidence-based interventions, while activity-based therapies improved engagement and well-being. However, significant variability in study designs and small sample sizes limit generalizability.

Implications

For Practice OT practitioners should prioritize tailored interventions addressing patients’ specific functional deficits. Multidisciplinary collaboration is essential to enhance outcomes.

Future Research

Standardized intervention protocols and outcome measures are critical to building a robust evidence base. Long-term studies evaluating sustained impacts are also needed.

Conclusion

Occupational therapy offers valuable strategies to improve the functional and social outcomes of individuals with schizophrenia. Despite promising findings, more rigorous and standardized research is required to guide clinical practice and optimize patient outcomes.

References

American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., Text Revision). Arlington, VA: American Psychiatric Publishing.
Barlati, S., Morena, D., Nibbio, G., Corsini, P., & Vita, A. (2020). Cognitive remediation in schizophrenia: Current status and future perspectives. Schizophrenia Research and Treatment, 2020, 1–9. https://doi.org/10.1155/2020/8894814
Bellack, A. S., Mueser, K. T., Gingerich, S., & Agresta, J. (2004). Social Skills Training for Schizophrenia: A Step-by-Step Guide (2nd ed.). New York: Guilford Press.
Birchwood, M., & Trower, P. (2006). The future of cognitive–behavioral therapy for psychosis: Not a quasi-neuroleptic. British Journal of Psychiatry, 188(2), 107–108. https://doi.org/10.1192/bjp.bp.105.012153
Browne, J., Chang, A., & Kerr, S. (2021). Occupational therapy for schizophrenia: A meta-analysis of intervention effectiveness. Occupational Therapy International, 2021, 1–14. https://doi.org/10.1155/2021/6502328
Buchanan, R. W., & Carpenter, W. T. (2020). Conceptualizing negative symptoms in schizophrenia. Schizophrenia Bulletin, 46(4), 732–736. https://doi.org/10.1093/schbul/sbaa003
Bucci, S., Barrowclough, C., & Haddock, G. (2015). The role of psychological interventions in improving functioning in schizophrenia. Clinical Psychology Review, 35, 43–54. https://doi.org/10.1016/j.cpr.2014.11.002
Carruthers, C., & Hood, C. D. (2007). The power of the positive: Leisure and well-being. Therapeutic Recreation Journal, 41(1), 16–37.
Chan, R. C., Li, H., Cheung, E. F., & Gong, Q. (2018). Impaired cognitive functioning in schizophrenia: Mechanisms and implications. Neuroscience Bulletin, 34, 102–112. https://doi.org/10.1007/s12264-017-0132-8
Chien, W. T., & Lee, I. Y. (2013). The effectiveness of psychosocial interventions for patients with schizophrenia. Journal of Advanced Nursing, 69(9), 1908–1921. https://doi.org/10.1111/jan.12043
Craig, T., Garety, P., & Power, P. (2004). The Lambeth Early Onset (LEO) Team: Randomised controlled trial of the effectiveness of specialised care for early psychosis. BMJ, 329(7474), 1067. https://doi.org/10.1136/bmj.38246.594873.7C.