Dr. L. L. Amila Isuru

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IMPACT OF A DRAMA, DANCE, YOGA AND MUSIC THERAPY WORKSHOP ON SYMPTOM REDUCTION IN A GROUP OF PATIENTS WITH SCHIZOPHRENIA A RANDOMIZED CONTROLLED TRIAL

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Slide1:

IMPACT OF A DRAMA, DANCE, YOGA AND MUSIC THERAPY WORKSHOP ON SYMPTOM REDUCTION IN A GROUP OF PATIENTS WITH SCHIZOPHRENIA A RANDOMIZED CONTROLLED TRIAL Isuru LLA, Dahanayake DMA, de Alwis A, Hewage SN, Weeresinghe A, Ranasinghe CK. Colombo North Teaching Hospital , Sri Lanka

Impact of a drama, dance, yoga and music therapy workshop on symptom reduction in a group of patients with schizophrenia A Randomized Controlled Trial.:

Impact of a drama, dance, yoga and music therapy workshop on symptom reduction in a group of patients with schizophrenia A Randomized Controlled Trial. Isuru LLA, Dahanayake DMA, de Alwis A, Hewage SN, Weeresinghe A, Ranasinghe CK.

Need of Rehabilitation:

Need of Rehabilitation Schizophrenia is the third leading course of disability worldwide . ( Schizophrenia bulletin 2011) Patients who have received evidence based treatments show limited functional recovery. ( The OPUS trial, Arch Gen Psychiatry 2008)

Towards social integration:

Towards social integration

Introduction:

Introduction Drama, dance, yoga and music therapy separately is known to improve many deficits in schizophrenia Improve negative symptoms Improve cognitive symptoms Promote self-confidence Identification of emotions Enhance interpersonal communication Promote wellbeing

Yoga therapy and Schizophrenia:

Yoga therapy and Schizophrenia Positive and negative symptoms Varambally et al (2012) Reduced PANSS scores Nagendra et al (2000) Cognitive symptoms Bhatia et al (2012) Open, non-randomized trial Social skills Duraiswamy et al (2007) RCT Better than standard exercise regimes Quality of life (in the short term) Cramer et al (2013) A systematic review and meta-analysis

Drama therapy and schizophrenia:

Drama therapy and schizophrenia Bielańska et al (1991) Patients who would not benefit from traditional psychotherapy Spencer et al (1983) Drama therapy Effects are maintained long term Nitsun et al (1974) Movement and drama therapy with long-stay schizophrenics Ruddy et al (2007) Cochrane Database Syst Rev. Randomised controlled trials Inconclusive – harm or benefits

Music therapy and schizophrenia:

Music therapy and schizophrenia Mossler et al  (2011) Cochrane Database Syst Rev. Known to improve negative, social and global status Peng et al (2010) Reduction in BPRS scores Silverman (2003) A meta analysis Significantly effective in suppressing and combating the symptoms of psychosis Talwar et al (2005) Randomized controlled trial Improved symptoms in-patients with schizophrenia

Dance therapy and schizophrenia:

Dance therapy and schizophrenia Xia et al (2009) Cochrane Database Syst Rev. No evidence to support - or refute - the use of dance therapy Gunning et al (1973) Used dance therapy in psychotic children Inconclusive

Creative therapy (Self expressive therapy) Combinations of dance, drama, music and yoga :

Creative therapy (Self expressive therapy) Combinations of dance, drama, music and yoga

Creative therapy and schizophrenia :

Creative therapy and schizophrenia Difficult to identify studies that have used creative therapy in the treatment of schizophrenia Ruddy et al (2007) Cochrane Database Syst Rev. No conclusive findings Highly neglected in research world wide   No studies in a Sri Lankan setting

Creative Therapy workshop.:

Creative Therapy workshop.

Abhina academy of performing arts:

Abhina academy of performing arts Has worked with War victims Tsunami survivors Learning disabled individuals Child soldiers

Slide14:

Working with the 2004 Tsunami survivors

Slide15:

Working with war veterans

Working with child soldiers:

Working with child soldiers

Creative Therapy workshop for Schizophrenia:

Creative Therapy workshop for Schizophrenia Specifically addresses the following aspects Breathing control and practice Observations of other behaviour and mimicking Attention-enhancing procedures Maintaining correct body posture Enhancing self confidence through positive feedback Social interactions through drama, dance and group music Effective communication

Creative Therapy workshop for Schizophrenia:

Creative Therapy workshop for Schizophrenia Combined drama, music, dance and yoga in to a comprehensive programme Lasted – 8 days over 3 weeks 6 hours per day Formed a small therapeutic community with equal participation of therapist and participants in all activities Culminated with a talent show

Slide20:

Drama

Slide21:

Yoga

The study:

The study

Objectives:

Objectives To measure the effect of the creative therapy workshop for patients with schizophrenia on reduction of positive and negative symptoms Primary outcome variable – PANSS score on self confidence Secondary outcome variable – Rosenberg self-esteem score (RSES)

Methods:

Methods Study design Randomized controlled study (RCT trial registry number - SLCTR/2013/008) 73 patients with schizophrenia were randomly allocated to the Creative therapy workshop (Test group; n=33) ‘treatment as usual’ (Control group; n=40). Both groups were assessed PANSS scores before and after the end of the workshop Test group was assessed Rosenberg self-esteem scale (RSES) before and after the end of the workshop

Test group and control group:

Test group and control group TEST GROUP N = 33 (Non forensic patients – 23 + Forensic patients – 10) CONTROL GROUP N = 40 (Non forensic patients – 30 + Forensic patients – 10)

Results - Analysis:

Results - Analysis Baseline variables - PANSS and RSES did not follow normal distribution Shapiro-Wilk test of normality; P <0.001 Subsequent analyses were nonparametric Mann Whitney U test Wilcoxon signed rank test

Descriptive statistics:

Descriptive statistics Age Test Group Mean – 38.79 years (SD – 9.5) Minimum age – 22 years; Maximum age – 63 years Control group Mean – 41.88 years (SD – 9.7) Minimum age – 22 years; Maximum age – 65 years Sex Majority of the sample (both the test and control group) were male

Results Contd.:

Results Contd. The test group and the control group was comparable at the beginning of the trial, in terms of the PANSS scores including all subscales Age

Test Group Vs Control Group:

Test Group Vs Control Group Test Group (SD) Control Group (SD) P * Age (years) 38.99 (9.50) 40.97 (11.41) 0.213 PANSS Positive 16.82 (4.53) 17.63 (4.47) 0.486 PANSS Negative 19.24 (7.38) 18.60 (5.60) 0.541 PANSS General 33.30 (6.94) 32.63 (8.94) 0.418 PANSS Total 69.36 (15.54) 68.87 (14.12) 0.689 * Using the Independent samples Mann Whitney U test PANSS – Positive and negative syndrome scale (Kay et al, 1987), SD – Standard deviation Number of patients in each group; Test=37, Control=40

Pre and Post results for the test and control groups:

Pre and Post results for the test and control groups

* Using Wisconsin Signed Rank Test, 2-sided p:

* Using Wisconsin Signed Rank Test, 2-sided p Pre (Median [Interquartile range]) Post (Median [Interquartile range]) P* PANSS Positive Test 16.0 (14.0 – 19.5) 15.0 (10.0 – 17.5) <0.001 Control 17.0 (15.0 – 20.8) 16.0 (14.0 – 18.0) <0.001 PANSS Negative Test 18.0 (15.0 – 22.5) 17.0 (11.0 – 22.5) <0.001 Control 19.0 (16.0 – 22.8) 18.0 (15.0 – 22.0) 0.014 PANSS General Test 33.0 (30.0 – 37.5) 29.0 (24.0 – 33.5) <0.001 Control 32.0 (27.3 – 37.8) 29.0 (23.5 – 36.0) 0.001 PANSS Total Test 68.0 (63.5 – 77.0) 61.0 (49.5 – 72.0) 0.002 Control 68.0 (62.0 – 74.0) 63.5 (54.5 – 72.8) <0.001 RSES 24 (15 – 25) 23 (16 – 24) <0.001 PANSS – Positive and negative syndrome scale (Kay et al, 1987), RSES – Rosenberg self esteem scale (Rosenberg, 1965), Number of patients in each group; Test=37, Control=40

Forensic Patients Vs Non-forensic patients :

Forensic Patients Vs Non-forensic patients

Pre and Post results for the Forensic test and control groups:

Pre and Post results for the Forensic test and control groups

* Using Wisconsin Signed Rank Test, 2-sided p:

* Using Wisconsin Signed Rank Test, 2-sided p Group Pre (Median [Interquartile range]) Post (Median [Interquartile range]) P* PANSS Positive Test (Abhina) 16.00 (13.50 – 21.50) 16.00 (14.00 – 22.25) 0.703 Control 17.50 (14.75 – 22.00) 18.00 (14.25 – 22.50) 0.844 PANSS Negative Test (Abhina) 22.00 (18.75 – 24.5) 22.50 (18.75 – 25.50) 0.922 Control 22.00 (18.75 – 25.2) 22.50 (18.75 – 26.50) 0.531 PANSS General Test (Abhina) 32.00 (30.00 – 33.75) 32.50 (30.50 – 34.75) 0.875 Control 32.00 (33.50 – 30.75) 33.50 (30.75 – 35.75) 0.437 PANSS Total Test (Abhina) 69.00 (65.00 – 77.25) 70.00 (66.75 – 77.75) 0.844 Control 71.00 (68.75 – 77.75) 72.50 (69.25 – 80.75) 0.563 RSES Test (Abhina) 14.00 (13.5 – 15.00) 13.50 (11.75 – 16.00) 0.164 PANSS – Positive and negative syndrome scale (Kay et al, 1987), RSES – Rosenberg self esteem scale (Rosenberg, 1965), Number of patients in each group; Test=10, Control=10

Pre and Post results for the Non-Forensic test and control groups:

Pre and Post results for the Non-Forensic test and control groups

* Using Wisconsin Signed Rank Test, 2-sided p:

* Using Wisconsin Signed Rank Test, 2-sided p Group Pre (Median [Interquartile range]) Post (Median [Interquartile range]) P* PANSS Positive Test 17.00 (14.00 – 19.00) 13.00 (10.00 – 16.00) <0.001 Control 16.50 (15.00 – 20.25) 15.50 (13.75 – 17.00) <0.001 PANSS Negative Test 16.00 (13.00 – 19.00) 13.00 (10.00 – 17.00) 0.001 Control 17.50 (14.75 – 22.00) 17.00 (13.75 – 21.25) <0.001 PANSS General Test 34.00 (29.00 – 38.00) 26.00 (21.00 – 32.00) <0.001 Control 31.00 (23.75 – 39.25) 27.00 (22.00 – 36.25) <0.001 PANSS Total Test 68.00 (62.00 – 78.00) 52.00 (43.00 – 68.00) <0.001 Control 66.00 (61.50 – 74.00) 59.00 (52.75 – 69.25) <0.001 RSES Test 25.00 (24.00 – 25.00) 24.00 (23.00 – 24.00) <0.001 PANSS – Positive and negative syndrome scale (Kay et al, 1987), RSES – Rosenberg self esteem scale (Rosenberg, 1965), Number of patients in each group; Test=23, Control=30

Comparison of change in PANSS scores in the total sample (forensic population):

Comparison of change in PANSS scores in the total sample (forensic population) Test Change Score -Median ( Interquartile range) Control Change score- Median ( Interquartile range) P value* PANSS Positive 1 (0 – 5) 1 (0 – 3) 0.241 PANSS Negative 3 (0 – 4) 0 (0 – 1) 0.062 PANSS General 3 (0 – 8.5) 1 (0 – 2) 0.055 PANSS Total 7 (0.5 – 16) 2.5 (0 – 6) 0.082

Comparison of change in PANSS scores in the total sample (Non forensic population):

Comparison of change in PANSS scores in the total sample (Non forensic population) Test Change Score -Median [ Interquartile range] Control Change score- Median [ Interquartile range] P value* PANSS Positive 2 (1 – 6) 1 (0 – 4) 0 .048 PANSS Negative 3 (0 – 5) 0 (0 – 1.25) 0 .010 PANSS General 5 (2 – 11) 1.5 (0 – 2.25) 0 .004 PANSS Total 11 (3 – 22) 4 (1 – 7) 0 .006

Summery of findings:

Summery of findings Both groups showed highly significant improvements in all PANSS scores The test group showed a statistically significant improvement in all PANSS scores In the test group there was a highly significant improvement in the self-esteem score The forensic population of patients did not show a significant improvement in symptoms or self esteem

Conclusion:

Conclusion Exposure to dance, drama, yoga and music therapy can have a positive effect on self esteem as well as lead to symptom reduction in the short term in patients with schizophrenia

Discussion:

Discussion How does our study compare with the others? Results agree with most other studies Self confidence – not measured in any of the other studies Use of a forensic population – unique in our study

Why does it work?:

Why does it work? Mechanism is not clear May have effects on Improvement of Facial Emotional Recognition Deficits (FERD) Also seen by Bediou et al (2005) Also seen by Behere et al (2011) Corrections of deficits in the sphere of social cognition Also seen by Brune et al (2005) Attention-enhancing leading to cognitive remediation Also seen by Lewandowski et al (2011)

Discussion:

Discussion Limitations of the study Used in-patients who are being medicated and the clinical state is changing rapidly No long term follow up – the effects on long term

Thank You:

Thank You

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