Comparison 1. Psychological therapy versus treatment as usual

Comparison 2. Psychosocial therapy versus treatment as usual

Comparison 3. Occupational therapy versus treatment as usual

Comparison 4. Staff training intervention versus treatment as usual

The outcomes that matter most

The aim of this review was to compare the effectiveness of interventions to improve activities of daily living in people with complex psychosis and related severe mental illnesses. Activities of daily living (ADL) was therefore selected as a critical outcome for this review, and this was further defined as how people used their time and how involved they were in social activities. The committee agreed that relapse or readmission should be included as a critical outcome for decision-making as failure to carry out activities of daily living can be one of the main reasons for people being readmitted to a higher level of support or care. The committee also agreed that people who could participate in activities of daily living (looking after themselves, shopping, cooking, budgeting) were more likely to maintain a tenancy and therefore sustaining tenancy was prioritised as a critical outcome.

The committee agreed that being able to self-medicate and medication adherence were important outcomes as they both reflect the level of independence that people can maintain, and can impact the course of their mental health condition and hence included it as an important outcome. Improvement of quality of life is one of the main aims of the interventions and hence it was also included as an important outcome.

The quality of the evidence

The evidence for outcome activities of daily living ranged from very low to moderate quality as assessed using GRADE. Evidence was downgraded due to risk of bias arising from unclear randomisation methods and lack of blinding, and also imprecision resulting from confidence intervals including no effect. The evidence for readmission/relapse rate was very low quality, and was downgraded for risk of bias in included studies and imprecision. The evidence for quality of life ranged from very low to low quality and was downgraded due to risk of bias arising from unclear randomisation methods and selective reporting of outcomes. The evidence was also downgraded for imprecision. There was no evidence identified for sustained tenancy and self-medication/medication adherence.

There was a lack of evidence for exercise/physical therapy, peer support interventions and environmental adaptations & equipment.

Benefits and harms

The committee discussed the fact that there was some evidence that psychological therapy, delivered as social skills training, cognitive training, or as a social skills intervention, increased participation in ADLs. There was no benefit from any of the interventions on quality of life or readmission/relapse rates (although there was very limited evidence available for these outcomes).

The Independent Living Skills Scale (ILSS) had been used by 3 of the included studies (Leclerc, Bartels, Liberman): this scale measures functioning in 12 areas with a maximum score achievable of 112. The committee noted that although psychological interventions had led to an increase in these scores, the absolute changes were very small. However, it was also noted that in the treatment as usual (TAU) groups, the scores worsened, even though these people were receiving some treatment in the form of occupational therapy.

Another study (Thomas) had measured the impact of cognitive training using time units of ADLs, for example complete or partial days, and had found an increase in ADLs using this measure, and Edgelow used a measure of time use to determine the impact of an occupational therapy intervention and found no difference in time spent sleeping, on self-care, productively or on leisure.

The Killaspy study of a staff training intervention used data from clusters of units, not individuals, and so did not measure individual’s improvement due to the intervention, but instead the mean results obtained by the unit. This training intervention did not increase engagement in ADLs when measured in terms of time use or in terms of social skills (measured using a life skills profile). The committee discussed that this may be due to the follow-up time in this study, as by 12 months the staff training may have been forgotten.

The committee discussed the different interventions that had been provided as part of the studies, which included laptop-based cognitive training for 1 hour a day, 3 to 5 days a week, for 12 to 15 weeks; module-based training delivered by occupational therapists for 3 hours a day, 4 days a week for 6 months; multiple group meetings with 2 meetings a week for 12 weeks; 12 weekly individual sessions delivered by an occupational therapist, or a comprehensive 12 month skills, healthcare and social skills training programme with a 1 year follow-up programme. Due to the mixture of interventions offered, it was difficult for the committee to identify which of these interventions was the most effective and the committee also noted that the small size of the some of the studies and the very different follow-up periods (ranging from 3 months to 3 years) made drawing conclusions very difficult.

The committee also discussed the fact that the 6 studies included in the review had included different populations of people – some were inpatients and others were living in a community rehabilitation setting. The committee noted that is some settings there was less opportunity to develop ADLs (for example it was difficult to encourage people to prepare food if kitchen facilities were limited) and that this was an important consideration.

The committee agreed that adherence to medicines and managing one’s own medicines were important to activities of daily living, particularly given that other evidence reviews in the guideline found that medication adherence is associated with successful rehabilitation and transition through the rehabilitation pathway to more independent living. Given the lack of evidence for medication adherence and self-management interventions in this population, the committee made reference to the NICE guidelines on medicines adherence and medicines optimisation (see below in other factors the committee took into account). Based on their experience, the committee recommended against polypharmacy where possible, and a flexible approach to self management of medicines, with examples of approaches that could be taken. The committee also made a research recommendation for medication adherence for people using supported accomodation, given the lack of evidence for specific interventions, and noting that people in supported accommodation are likely to receive less support in medication taking than people in inpatient rehabilitation settings.

Based on their expertise and experience the committee recommended rehabilitation services should develop a culture which promotes interventions and an environment to improve daily living skills.

There was low quality evidence to support structured group activities in terms of improved interpersonal function. The same evidence was negative for group art therapy but the committee thought this was likely due to the implementation of the activity in the trial rather than the intervention itself. Structured group activities are considered key to promoting ADLs in rehabilitation services – they are usual practice and monitored by the CQC. Therefore, the committee made a strong recommendation that staff in the rehabilitation service should support the involvement of people in rehabilitation in structured group activities and receive training to support interventions to promote people’s daily living skills and involvement in structured group activities.

They recommended these activities should include self-care activities, laundry, shopping, budgeting, using public transport, cooking and communicating. These skills were seen as an important step in enabling independence. The committee agreed based on their experience that ADL interventions would be more useful if targets were planned and reviewed with the person themselves, if the activities were enjoyable and motivating, and if they were done in real life-settingss wherever feasibile.