COGNITIVE DEFICITS AMONG SUPPORTED EMPLOYMENT CLIENTS WITH SCHIZOPHRENIA

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(1)M. al. ay. a. COGNITIVE DEFICITS AMONG SUPPORTED EMPLOYMENT CLIENTS WITH SCHIZOPHRENIA. U. ni. ve r. si. ty. of. DR NORMALA BINTI SORIKAN. FACULTY OF MEDICINE UNIVERSITY OF MALAYA KUALA LUMPUR 2019.

(2) ay. a. COGNITIVE DEFICITS AMONG SUPPORTED EMPLOYMENT CLIENTS WITH SCHIZOPHRENIA. si. ty. of. M. al. DR NORMALA BINTI SORIKAN. U. ni. ve r. DISSERTATIONS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE MASTER IN PSYCHOLOGICAL MEDICINE. FACULTY OF MEDICINE UNIVERSITY OF MALAYA KUALA LUMPUR 2019.

(3) UNIVERSITI MALAYA ORIGINAL LITERARY WORK DECLARATION. Name of Candidate: Normala binti Sorikan Registration/Matric No: MGC150002 Name of Degree: Master of Psychological Medicine Title of Project Paper/Research Report/Dissertation/Thesis (―this Work‖):. a. ―Cognitive deficit among supported employment clients with schizophrenia‖. ve r. si. ty. of. M. al. ay. Field of Study: I do solemnly and sincerely declare that: (1) I am the sole author/writer of this Work; (2) This Work is original; (3) Any use of any work in which copyright exists was done by way of fair dealing and for permitted purposes and any excerpt or extract from, or reference to or reproduction of any copyright work has been disclosed expressly and sufficiently and the title of the Work and its authorship have been acknowledged in this Work; (4) I do not have any actual knowledge nor do I ought reasonably to know that the making of this work constitutes an infringement of any copyright work; (5) I hereby assign all and every rights in the copyright to this Work to the University of Malaya (―UM‖), who henceforth shall be owner of the copyright in this Work and that any reproduction or use in any form or by any means whatsoever is prohibited without the written consent of UM having been first had and obtained; (6) I am fully aware that if in the course of making this Work I have infringed any copyright whether intentionally or otherwise, I may be subject to legal action or any other action as may be determined by UM.. Date:. ni. Candidate‘s Signature:. U. Subscribed and solemnly declared before, Witness‘s Signature. Date:. Name: Associate Professor Dr. Koh Ong Hui Designation: Senior Lecturer and Consultant Psychiatrist, Department of Psychological Medicine, Faculty of Medicine, University of Malaya (UM). ii.

(4) ABSTRACT Cognitive deficits are related to impairment in functional abilities. As the goal of treatment for schizophrenia is broader in that it involves not only clinical remission but also functional recovery, employment is one aspect of the recovery process. In schizophrenia patients, they have more difficulties in maintaining rather than acquiring a job despite of on-going job support and coaching. The aim of this study is to examine. a. the association of deficit in specific cognitive domains as the predictive factor of. ay. employment outcome.This is a cross-sectional study. Sixty two (n=62) participants who. al. were enrolled under the supported employment programme in Hospital Permai for at least one month were recruited and categorized under either the working or terminated. M. group (31 participants in each group). They were assessed with six cognitive tests that. of. corresponded to three cognitive domains (processing speed, working memory and executive function) based on the MATRICS Consensus Cognitive Battery. The. ty. terminated groups were assessed for the reasons of termination using Job Termination. si. Interview. The neurocognitive tests were done once and simultaneously between the. ve r. two groups during the study period. There is a significant difference in the level of working memory, speed of processing and reasoning and problem solving between. ni. working and terminated group with p value < 0.001. Analysis on association between. U. cognitive deficit and job termination showed there is significant association between. deficit in working memory, speed of processing and executive function with job termination. However, from the multivariate analysis, among the three cognitive. domains, only working memory deficit (p<0.05) has significant association with job termination.There is significant association between primary reason of termination and working memory deficit with p value < 0.05. The highest percentage of primary reason is problem with work quality among working memory deficit group. However, we are unable to prove that the work quality has significant association with working memory iii.

(5) deficit by using logistic regression test. Deficit in working memory is significantly a predictor of employment outcome in schizophrenia patients despite of ongoing job support in supported employment program. Further studies with larger sample size are needed to explore this area of research. Pilot study on cognitive remediation therapy is also recommended. Keywords: Schizophrenia, Cognitive deficit, Job Termination, Supported Employment,. U. ni. ve r. si. ty. of. M. al. ay. a. Malaysia. iv.

(6) ABSTRAK. Kekurangan fungsi kognitif adalah berkait rapat dengan kemerosotan dalam kebolehan berfungsi termasuk fungsi didalam aktiviti harian, kebolehan bersosial dan bekerja. Matlamat dalam rawatan penyakit skizofrenia adalah lebih meluas daripada kesembuhan klinikal;tetapi juga melibatkan fokus kepada pemulihan fungsi. Oleh itu, pekerjaan adalah salah satu kunci aspek didalam proses pemulihan. Bagi pesakit. a. skizofrenia, mereka mempunyai lebih kesukaran dalam mengekalkan pekerjaan dari. ay. memperolehi pekerjaan. Kebanyakan pesakit ini mempunyai tempoh pekerjaan yang. al. singkat dan menamatkan pekerjaaan secara tidak memuaskan. Tujuan kajian ini adalah. M. untuk memeriksa hubungkait antara kekurangan fungsi kognitif spesifik dengan hasil pekerjaan dikalangan klien program sokongan pekerjaan yang menghidapi skizofrenia.. of. Kajian ini merupakan kajian keratan rentas. Seramai enam puluh dua (n=62) peserta yang telah didaftarkan di bawah program sokongan pekerjaan di Hospital Permai. ty. sekurang-kurangnya selama satu bulan dan memenuhi kriteria terpilih akan direkrut dan. si. dikategorikan samada dibawah kumpulan yang bekerja atau sudah ditamatkan menggunakan enam ujian kognitif yang. ve r. pekerjaan. Penilaian akan dijalankan. bersamaan dengan penilaian tiga kawasan fungsi kognitif (kelajuan pemprosesan,. ni. ingatan kerja dan fungsi eksekutif) berdasarkan MATRICS Consensus Cognitive. U. Battery. Kumpulan yang diberhentikan kerja juga dinilai berkenaan alasan pemberhentian kerja menggunakan Job Termination Interview. Ujian kognitif telah dijalankan sekali dan serentak diatara dua kumpulan tersebut sewaktu tempoh kajian dijalankan. Seramai 62 peserta telah didaftarkan untuk kajian ini dengan 31 peserta didalm setiap kumpulan (bekerja dan ditamatkan pekerjaan). Terdapat perbezaan diantara tahap kelajuan pemprosesan, ingatan kerja dan fungsi eksekutif diantara kumpulan yang bekerja dan yang ditamatkan pekerjaan dengan nilai p <0.001. Analisis mengenai hubungkait antara kekurangan fungsi kognitif dan penamatan pekerjaan v.

(7) menunjukkan hubungan yang signifikan diantara kekurangan tahap kelajuan pemprosesan, ingatan kerja dan fungsi eksekutif dengan penamatan pekerjaan. Walaubagaimanapun, daripada analisis multivariat, hanya kekurangan daya ingatan kerja mempunyai hubungan signifikan dengan penamatan pekerjaan.Terdapat juga hubungan signifikan diantara alasan utama penamatan pekerjaan dan daya ingatan kerja (p<0.05). Peratusan tertinggi diantara sebab-sebab utama penamatan pekerjaan adalah. a. masalah kualiti kerja dikalangan kumpulan yang mempunyai kekurangan daya ingatan. ay. kerja. Walaubagiamnapun, kami tidak dapat membuktikan bahawa masalah kualiti kerja mempunyai hubungkait yang signifikan dengan kekurangan daya ingatan kerja dengan. al. menggunakan logistic regression test. Kekurangan daya ingatan kerja adalah factor. M. ramalan penamatan pekerjaan. Sebab utama pemberhentian pekerjaan mempunyai hubungkait dengan asas daya ingatan kerja. Walaubagaimanapun, pembuktian. of. hubungkait antara masalah kualiti kerja dan kekurangan daya ingatan kerja tidak dapat. ty. dibuktikan dalam kajian ini. Kajian akan datang memerlukan saiz sampel yang lebih. si. besar untuk meneroka bidang kajian ini. Kajian rintis keatas cognitive remediation. U. ni. ve r. therapy adalah disyorkan.. vi.

(8) Acknowledgements. I would like to express my deep gratitude to Professor Koh Ong Hui and Dr Abdul Kadir Abu Bakar, my research supervisors, for their patient guidance, enthusiastic encouragement and useful critiques of this research work. I would also like to thank Dr.Alipah Bahrum, for her advice and assistance in keeping my progress on. ay. a. schedule. My grateful thanks are also extended to Puan Siti Aisyah for her help in doing the statistical data analysis.. al. I would also like to extend my thanks to the Dr Badiah, the Director of Hospital. M. Permai, all case managers of supported employment program under Occupational Therapy Unit and Outpatient Department Unit Hospital Permai Johor Bahru for their. of. help in offering me the resources in running the study.. ty. Finally, I wish to thank my parents and spouse for their support and. U. ni. ve r. si. encouragement throughout my study.. vii.

(9) TABLE OF CONTENTS. Page. DECLARATION. ii. ABSTRACT. iii. ABSTRAK. v. ACKNOWLEDGEMENT. vii. a. CONTENT. ay. TABLE OF CONTENTS. al. LIST OF FIGURES. M. LIST OF TABLES ABBREVIATIONS. xi xii xiii xiv. si. ty. of. LIST OF APPENDICES. viii. 1. CHAPTER 2 : LITERATURE REVIEW. 4. 2.1: Neurocognition in Schizophrenia. 4. 2.2 Neurocognition and Functional Outcome. 7. 2.3 Employment and Recovery Model. 11. 2.4 Supported Employment Program. 16. 2.5 Job Termination in Supported Employment Program. 19. 2.6 Conceptual Framework. 22. CHAPTER 3: OBJECTIVE AND RESEARCH HYPOTHESIS. 23. 3.1 Rationale of Study. 23. U. ni. ve r. CHAPTER 1: INTRODUCTION. viii.

(10) 23. 3.3 Objectives. 24. 3.4 Research Hypothesis. 25. CHAPTER 4: METHODOLOGY. 26. 4.1 Study Setting and Study Period. 26. 4.2 Research Design. 27. 4.3 Study Population. 27. a. 3.2 Research Questions. ay. 4.3.1 Reference Population 4.3.2 Source Population. al. 4.3.3 Sampling Frame. M. 4.3.4 Study Sample. 29 29 29 30. 4.3.4.2 Exclusion Criteria. 30. of. 4.3.4.1 Inclusion Criteria. ty. 4.3.5 Sampling Method. si. 4.3.6 Sample Size 4.4 Research Tools. 30 31 32 32. 4.4.2 Mini International Neuropsychiatric Interview (MINI) 7.0.2. 36. 4.4.3 Job Termination Interview (JTI). 36. 4.4.4 Socio-demographic, Employment and clinical data. 37. ve r. 4.4.1 Neurocognitive Test. ni U. 29. 4.5 Operational Criteria. 37. 4.6 Variables. 39. 4.7 Minimising Study Error. 39. 4.8 Ethical Consideration. 39. 4.8.1 Informed consent in patients with severe mental illness. 40. 4.8.2 Subject withdrawal criteria. 40 ix.

(11) 4.8.3 Confidentiality. 40. 4.9 Statistical Analysis. 41. 4.10 Data Analysis Strategy. 41. 4.11 Study Flow Chart. 43. CHAPTER 5: RESULTS. 44. 5.1 Socio-demographic and clinical data among supported employment clients 44. a. with schizophrenia. ay. 5.2 Level of working memory, speed of processing and executive function 46 among schizophrenia clients. al. 5.3 Comparison of socio-demographic and clinical data between terminated 48. M. and working group. 5.4 Comparison in level of cognitive function among terminated and working 50. of. group. ty. 5.5 Relationship of job termination and cognitive deficit 5.6 Primary reason of job termination. 52 54. si. 5.7 Association of client‘s primary reason for job termination with underlying 55. ve r. true cognitive deficit. 58. CHAPTER SEVEN: LIMITATIONS AND RECOMMENDATIONS. 69. CHAPTER EIGHT: CONCLUSION. 71. REFERENCES. 74. U. ni. CHAPTER SIX: DISCUSSION. x.

(12) LIST OF FIGURE Figure 2.6 Conceptual framework. 21. Figure 4.11 Study flowchart. 42. Figure 5.2 Mean of T score in 3 cognitive domains namely working memory, 46 speed of processing and executive function (reason and problem solving) 53. U. ni. ve r. si. ty. of. M. al. ay. a. Figure 5.6 Primary reason of job termination by clients. xi.

(13) LIST OF TABLES Table 5.1 Characteristics of the Participants (n = 62). 44. Table 5.2 : Mean of MCCB Score for schizophrenic population under supported 45 employment programme (n=62) Table 5.3 Demographic variable and employment status from bivariate analysis 47 (n = 62). a. Table 5.4 (a) Frequency and percentage of cognitive deficit between terminated 49. ay. and working group. 49. al. Table 5.4 (b) Comparison of the level of cognitive domains between terminated and working group. M. Table 5.5 (a) Factors associated with job termination using simple logistic 51. of. regression. Table 5.5 (b) Cognitive domains associated with job termination using multiple 52. ty. logistic regressions. si. Table 5.7.1 (a) Association of client‘s subjective primary reasons for job 54. ve r. termination with working memory. Table 5.7.1 (b) Association of client‘s subjective primary reasons for job 55. ni. termination with speed of processing. U. Table 5.7.1 (c) Association of client‘s subjective primary reasons for job 55 termination with working memory Table 5.7.2 Association of client‘s subjective primary reason for job termination 56 with deficit in working memory using simple logistic regression. xii.

(14) LIST OF ABBREVIATIONS. Brief Assessment in Cognition in Schizophrenia. BVMT-R. Brief Visuospatial Memory Test-Revised. CI. Confidence Interval. DSM 5. Diagnostic and Statistical Manual 5. LNS. Letter Number Span. MATRICS. Measurement And Treatment Research to Improve Cognition in. al. ay. a. BACS. Matrics Consensus Cognitive Battery. M.I.N.I. Mini International Neuropsychiatric Interview. NAB. Mazes Neuropsychological Assessment Battery Mazes. SD. Standard Deviation. SE. Supported Employment. SMI. ty. of. M. MCCB. si. Schizophrenia. ve r. Severe Mental Illness Statistical Package for Social Sciences. TMT. Trail Making Test. ni. SPSS. Wechsler Memory Scale-third edition. U. WMS III. xiii.

(15) LIST OF APPENDICES APPENDIX I: M.I.N.I 7.0.2 Module K APPENDIX II: TRAIL MAKING TEST-A Test Sheet APPENDIX III: BACS – SYMBOL CODING Test Sheet APPENDIX IV: BRIEF ASSESSMENT OF COGNITION IN SCHIZOPHRENIA (BACS). a. – CATEGORY FLUENCY Test Sheet. ay. APPENDIX V: WECHSLER MEMORY SCALE-THIRD EDITION (WMS-III):. al. SPATIAL SPAN Test Sheet (Forward and Backward). LETTER-NUMBER SPAN Test Sheet. M. APPENDIX VI :WECHSLER MEMORY SCALE-THIRD EDITION (WMS-III):. MAZES Test Sheet (A to G). of. APPENDIX VII: NEUROPSYCHOLOGICAL ASSESSMENT BATTERY (NAB) –. ty. APPENDIX VIII: JOB TERMINATION INTERVIEW. si. APPENDIX IX: Demographic and Clinical Data Sheet. ve r. APPENDIX X: Consent Form and Patient Information Sheet (Malay). U. ni. APPENDIX XI: Consent Form and Patient Information Sheet (English). xiv.

(16) CHAPTER 1 INTRODUCTION Bleuler first recognized impairment of cognitive function in schizophrenia. They described that cognitive deficit as one of the core symptoms of schizophrenia (Bleuler, 1952). The argument is that the deficits may be present since the first manifestations of. a. the disease or may appear before the onset of symptoms. Moreover, the cognitive. ay. deficits have been related to impairment in multiple functional abilities included psychological, social and occupational functioning (Goldberg and Gold 1995). The. al. functional disabilities eventually would compromise a person‘s ability to lead an. M. independent life, to benefit from psychosocial treatments, to create and maintain social. of. relationships, to find and keep a job, and to maintain academic development. Hence, schizophrenia has been placed as among the most costly illness in the world due to these. ty. functional disabilities high rehospitalisation rates, poor employment status with the need. si. to support their disability benefits at an early age. Thus, the focus has been shifted to. ve r. improve functional recovery, and it is the target of psychopharmacological treatment of this illness.. ni. It is approximately 80% of patients with schizophrenia has a significant. U. cognitive deficit when compared to healthy persons (Reichenberg et al., 2009), and this deficit may affect up to 98% of the patients when pre-morbid functioning is considered (Keefe et al., 2005). The most replicated deficits are related to attention, memory and executive functions (Heinrichs and Zakzains, 1998; Keefe et al., 2004). These specific cognitive deficits were found to correlate with the functional outcome of schizophrenia (Green, 1996). Employment has been recognized as an essential tool in the treatment of people with severe mental illness (SMI) to promote functional recovery. It has become one of 1.

(17) the crucial components in psychiatric rehabilitation. There are many positive effects from employment included providing income, improve social function, self-esteem, quality of life, insight, treatment compliance and symptom (Marwaha and Johnson, 2004). With the availability of supported employment program which is evidence-based vocational rehabilitation program, clients could acquire competitive employment doubled that provided by traditional vocational rehabilitation (Bond GR et al., 2008).. a. However, available evidence might suggest that people with psychiatric disabilities have. ay. more difficulties in maintaining rather than acquiring a job despite on-going job support and coaching. Local study done by Wan Kassim et al., 2014 reported that up to 68.3% of. al. clients with severe mental illness were successfully maintaining their job at 3 months. M. upon being enrolled into an employment program, which this number is relatively high rate compared to studies done by western country that showed lower rates of job. of. maintenance (Wan Kassim et al., 2014). Cook et al. reported 39% of patients in the. ty. supported employment program worked for 40 or more hours in a month (JA Cook et. si. al., 2005).. In order to accommodate patient that were enrolled in supported employment. ve r. program and to prolong the job tenure, assessment on job termination would be beneficial. One potential avenue by which to improve employment success is to address. ni. the factors that can impede the ability to learn job assignments and acquire other work-. U. related skills necessary to succeed in a competitive work environment. The neurocognitive deficit is widely viewed as a core feature of schizophrenia. It affects the vast majority of individuals with the disorder and is related to community and work functioning. Verbal learning, attention, working memory, and reasoning and problemsolving ability have been shown to be related to work outcome (e.g., hours worked, wages earned), work behavior (e.g., work quality) and job tenure (Green et al., 2000).. 2.

(18) These findings suggest that specific cognitive deficits may be critical determinants of work functioning and merit consideration as a target of treatment intervention. In the local setting, there is still a lack of evidence in the outcome of supported employment program as rehabilitation for the patient with schizophrenia specifically in the aspect of job termination. Hence, this study is conducted to look for the relationship between cognitive. a. deficit and job terminations among supported employment clients with schizophrenia.. ay. By having more available findings on factors affecting job tenure, the refinement of the supported employment program can be implemented in order to improve the success of. U. ni. ve r. si. ty. of. M. al. our vocational rehabilitation based on our local setting.. 3.

(19) CHAPTER 2 LITERATURE REVIEW 2.1 Neurocognition in schizophrenia Schizophrenia is a chronic debilitating psychiatric illness. It consists primarily of positive and negative symptoms as well as cognitive symptoms.Schizophrenia is affecting more than 21 million people worldwide (WHO, 2015). In 2013, schizophrenia. a. was ranked among the top 25 leading causes of disability worldwide (Vos T et al.,. ay. 2013). In the past, neurocognition is not recognised as the primary outcome and core features of schizophrenia. It is believed to be minimal and simply explained as the. al. consequences of schizophrenia clinical symptoms or the medication effects. However, in. M. the recent few decades, this belief has been replaced to the more contemporary belief on. of. cognitive deficit in schizophrenia as the core features of the illness (Green et al, 2004b) For nearly three decades prior to this study, the research on neurocognition in. ty. schizophrenia has grown vastly up to fivefold (Hyman and Fenton 2003). The key point. si. of rapid growth of research on neurocognition is because the concern has shifted to. ve r. cognitive deficit as a fundamental aspect of schizophrenia and it has become recognised as the only factor that strongly correlated with real world functioning, hence a target of. ni. intervention (Green, 1996).. Neurocognition is all of one's mental abilities, performances on various measures. U. of cognitive domains such as attention, memory, processing speed, visuospatial ability and executive functions. Based on research on developing consensus battery for cognitive assessment, 7 cognitive domains identified by the MATRICS (verbal learning and memory, visual learning and memory, working memory, speed of processing, reasoning and problem solving, attention, and social cognition) that are impaired in schizophrenia (Marder SR, Fenton W, 2004; Nuechterlein KH et al.,2004). Evidence reported that the cognitive deficit among schizophrenia population is between one to two 4.

(20) standard deviations below the healthy controls that in this context refer to a wide range of performance deficits in any of the cognitive domains area (Riley EM, et al., 2000). The evidence from more recent studies show that. the cognitive deficit is more. generalised (Dickinson et al., 2008) rather than affecting a single domain of cognitive function, but specific domains such as executive function might have a relatively greater impairment than others (Bilder et al. 2000). However, the underlying neurobiological. a. changes that caused the pervasive cognitive deficit are still uncertain.. ay. Among the earliest study on neurocognition, scholars have found that almost all patients with schizophrenia present moderate to severely impaired cognitive function. al. (Heinrichs and Zakzanis, 1998, Keefe et al, 2005). Up to 90% of patients were estimated. M. to have at least one cognitive domain that is significantly impaired (Palmer et al., 1997). The more recent finding found that there was up to 75% of patient with schizophrenia. of. suffered from cognitive impairment (PD. Harvey, 2013). This value exceeded the. ty. prevalence of impairment in other neurological disorders. A study in our local setting on. si. the prevalence of cognitive impairment in the schizophrenic population in Malaysia was as high as 80% (Ibrahim et al., 2009).. ve r. The temporal relationship of schizophrenia with neurocognition remains. inconclusive. While some scholars argue that cognition in schizophrenia remains stable. ni. over time and does not decline more rapidly than in healthy controls (Russell et al.,. U. 1997, Gold S et al., 1999), other researchers have found significant declines from premorbid intellectual capacity among individuals with schizophrenia (Sheitman et al., 2000). Nevertheless, as mentioned before, in general, scholars consistently agree that cognitive deficits are core features of schizophrenia (Goldberg and Green 2002). There are a few evidences that support this theory. One of the evidences is that patients with schizophrenia display neurocognitive deficit during and prior to their first presentation. 5.

(21) of clinical symptoms (Saykin et al. 1994). Moreover, their first-degree relatives who are not clinically manifesting schizophrenia symptoms also demonstrated similar cognitive deficit (Asarnow et al 2002). There was no correlation of psychotic symptoms with the cognitive deficit. Hence, despite clinical remission, the neurocognitive deficit was persistently present and impaired patients‘ process of functional recovery. Although there is reported evidence. regarding the presence of a correlation between poor. a. cognitive function in schizophrenia with negative symptoms (Ventura et al. (2009)),. ay. research has proven that antipsychotics are effective in treating clinical symptoms but have much smaller effects in cognition, though second generation showed better This is suggestive that clinical. al. cognitive advantages (Harvey and Keefe 2001).. M. symptoms of schizophrenia and cognitive deficit have different underlying neural pathways. Concerns have been given for the development of modalities of treatments in. of. targeting cognitive deficit because it is recognized as the core integral element of. ty. functional recovery among the schizophrenic population. This relationship of cognitive. si. deficit with poor functional outcome was noted since the beginning of the twentieth century, first by Bleuler. However, the focus was later shifted towards the treatment of. ve r. positive symptoms due to the introduction of typical antipsychotics. Nevertheless, despite clinical remission, most patients still did not return to their premorbid. ni. functioning with high unemployment rates. Hence, since 1990s, the efforts in the. U. development of effective interventions targeting neurocognitive functions improvement became the crucial in the treatment of schizophrenia (T. Sharma, 2001).. The aim of the. treatment in schizophrenia is not only limited to clinical remission but also in the larger aspects of illness recovery.. 6.

(22) 2.2 Neurocognition and functional outcome Most of schizophrenia patients have some extent of functional impairment even during the first onset of the illness and tend to remain even after the treatment is initiated (Hafner & an der Heiden, 2003). The critical aspect of the presence of cognitive deficit among the schizophrenic population is the decline in their premorbid psychological,. a. social and occupational functioning that is required to have been observed at least six. ay. months before the diagnosis of schizophrenia can be made, based on Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association,. al. 2013). Schizophrenia can be considered the most expensive psychiatric disorder to treat,. M. as well as among the most expensive illness in the world (P. Andlin-Sabocki et al., 2005). The functional impairment that caused the productivitiy losses is a major. of. component that significantly contributes to the cost of the illness (E.Q Wu, 2005). In. ty. many countries, most patients with schizophrenia receive medical benefit from the. si. public fund for their support that caused dependence that develops during early of their illness. This financial support also applies to our local setting whereby schizophrenic. ve r. patients will receive financial aids from the social welfare department and classified as disabled persons.. ni. About a third of the schizophrenic population or roughly 20-30% of them has. U. full recovery whereas a smaller portion might have functional deterioration in the aspect of psychological, social and occupational functioning before old age (R. Warner,2009). In the aspect of social function, there was less than 10% of all male patients with schizophrenia ever have a child (Nanko S et al., 1993), which shows that this illness manifests as difficulty in initiating and maintaining social function. In general, scholars agree on schizophrenia causing a certain extent of occupational functioning impairment. Up to 10% of patients with schizophrenia are working full-time in competitive. 7.

(23) employment whereas 20% are working on a part-time basis (Lehman et al., 2002). Locally, the National Malaysian Schizophrenia Registry reported in 2008 that the unemployment rate was up to 70% among the schizophrenic population. Other than social and occupational functioning that is affected by the illness, patients‘ ability to practice independent living is also affected. The phenomena became apparent after the era of deinstitutionalization, with high rates of homelessness among schizophrenic. a. patients (Scott et al., 1993). This issue of homelessness is a reflection of the difficulty. ay. that this population experienced in terms of independent living.. Thus, the goal of treatment in schizophrenia is currently broader from clinical. al. remission to improve real-world functional outcome. The growing body of literature has. M. reported that neurocognitive deficit is the best predictor of various types of functional outcome in daily life activity, including social functioning, occupational and educational. of. functioning as well as the psychosocial rehabilitation skills acquisition among. ty. schizophrenic patients (Green, 1996; Green et al., 2000). Hence, during the last two. si. decades, concern has been shifted towards the cognitive deficits as the essential target of psychopharmacological intervention as it will affect the functional outcome that is the. ve r. major part of illness recovery.. Schizophrenia is known to be affected across several numbers of cognitive. ni. domains. Although the most robust evidence reported that patients with schizophrenia. U. have global neurocognitive deficit that associated with real-world functioning, ( JD Evans et al., 2003), some evidence shows that there are several discrete domains of cognitive function that are consistently replicated and associated with specific functional outcomes (M.F. Green et al. 2000). From this meta-analysis study by Green that involved 37 studies, it was found that there are significant modest to large associations between immediate memory, verbal memory, vigilance, and executive functioning with functional outcomes in schizophrenia. Further evidence that also supported on functional. 8.

(24) skills are correlated with discrete domains of neurocognitive impairment is a study done by McClure et al. in 2007 that divided the functional outcomes into two domains which are daily living skills and social competence. Daily living skills are found to be associated with the performance of the speed of processing, working memory and executive functions whereas social competence is associated with the performance of verbal fluency. This argument is still left to be controversial.. a. Employment is one of the components of functional recovery in schizophrenia. It. ay. has a vital role in the process of functional recovery. In this study, our interest is on looking for the relationship of specific neurocognitive domains with the employment. al. outcome. Similar to the above finding on how the discrete domains of cognitive. M. impairment affect specific functional outcomes, some evidence reported that deficit in specific cognitive domains could affect the employment outcome. These cognitive. of. domains include working memory, executive function, and speed of processing that. ty. were consistent to be found as predictive factors of the success in employment (T.. si. Sharma et al., 2003; C.R. Bowie et al. 2008). There is other supporting evidence that was presented by S. Shamsi et al. in 2011, where they reported a discrete domain of. ve r. neurocognitive deficits that significantly associated with specific functional outcome. Working memory performance is reported to be associated with employment outcome. U. ni. whereas verbal memory scores predict independent living. In this study, our focus is more on the relationship between specific. neurocognitive domains with employment outcome among supported employment clients with schizophrenia. Thus, by using MATRICS Consensus Cognitive Battery (MCCB) neuropsychological battery as our neurocognitive tools, we are only concentrating on three discrete cognitive domains that were assessed in this study. These three cognitive domains are working memory, executive function and speed of processing, to look for its association with an employment outcome.. 9.

(25) Working memory is a part of a temporary memory system which involves maintaining and manipulating information. There are few activities involved in working memory including holding the information for a short duration, processing as well as manipulation of the information (CR. Bowie, PD Harvey 2006). In schizophrenia, both verbal and spatial working memories were affected. The second cognitive domain is the executive function that consists of a wide. a. range of cognitive process that results in purposeful behavior. It refers to the ability to. ay. use abstract concepts, to arrange steps in problem-solving, to make a plan on action and execute them as goal-directed behavior under their self-monitoring using both mental. al. and physical process CR. Bowie, PD Harvey 2006). It involves adaptive behavior and. M. planning.. The third cognitive domain is processing speed which is a cognitive ability that. of. could be defined as the ability to process new information efficiently and rapidly (S.. ty. Kalkstein et al. 2010). The assessment would be involved on how fast the speed or. si. duration of time taken for a person to respond on the information given either in visual, auditory or movement.. ve r. The National Institute of Mental Health (NIMH) developed the Measurement. and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) as an early. ni. initiative to assist the development of treatment modalities for cognitive deficit in. U. schizophrenia. MATRICS first conference conducted in 2004 to develop consensus on a neuropsychological battery. With the presence of MATRICS Consensus Cognitive Battery (MCCB) since 2008, it facilitates and standardizes the cognitive assessment on clinical trials of intervention for cognitive-enhancing intervention for schizophrenia. The critical aspect of MCCB is a performance-based assessment of cognitive deficit that is related to daily activities. This linkage to functional outcome is a significant part of the reason for the cognitive deficit is considered as a crucial target of. 10.

(26) psychopharmacological intervention. MCCB is the assessment that was used in this study to assess the three cognitive domains.. 2.3 Employment and recovery model One essential point of assessment in the real world of functional outcome is the employment status. Schizophrenia has high unemployment rate due to reduced capacity. a. to work. Most of them are dependent on family members and disability payments (S.. ay. Marwaha et al., 2007). In Malaysia, National Mental Health Registry (NMHR) for. al. schizophrenia published its first paper in 2008 which show that the rate of. M. unemployment among schizophrenic patients was as high as 70% (Aziz et al., 2008). Thus, schizophrenia affects the economy and ranks among the top ten illnesses listed by. of. WHO that contribute to the global disease burden (C.J.L. Murray, A.D. Lopez.1996). Hence, the goal of treatment for schizophrenia is not solely limited to the clinical. si. quality of life.. ty. remission but in the broader aspect of functional recovery in order to improve their. ve r. For the past several years, significant attention has been given to the concept of recovery in schizophrenia. However, there is still a lack of consensus in the definition of. ni. the term ‗recovery‘. From the clinical point of view, and DSM 5 classification,. U. remission is described as six months duration of reduction of symptoms to half, a complete absence of symptoms. According to the Remission in Schizophrenia Working Group (RSWG) published in 2005 the consensus-derived, has defined the criteria for remission as the presence of a few numbers of core symptoms of the illness, at most, a mild intensity level of the symptoms which is not influencing an individual‘s behavior for a six months duration (Andreason et al. 2005). However, there is no consensus in regards to the definition of recovery. Liberman has proposed an operational definition of recovery. According to Liberman et al., recovery is a combination of symptoms 11.

(27) remission, a Brief Psychiatric Rating Scale (BPRS) score of 4 or less on psychosis items, engagement in productive activity either full or part-time work or education, independent living, and socializing with friends at least once a week, all sustained for a period of 2 years (Lieberman et al. 2002). However, Liberman suggests that there is also a subjective component that might contribute to the recovery process of schizophrenia. These individual components include considerations of internal hope, empowerment,. a. and illness self-management, availability of peer support and the way of coping with the. ay. effects of stigma.. The recovery model refers to the subjective experiences of hope, optimism,. al. empowerment and interpersonal support that was experienced by the patient with severe. M. mental illness, carer and service provider. This model became the base of optimism in finding the solution for recovery from mental illness at the same time provide. of. empowerment of the mentally- ill population towards the development of positive,. ty. recovery-oriented services that support human rights (R. Warner, 2009). The perspective. si. of this model can be divided into two perspectives. On the one hand, from the perspective of the consumer of mental health service that concentrates on empowerment. ve r. and recognition of human rights. In contrary, on the other hand, the professional rehabilitation focuses on the value of employment and community in providing support. ni. for people with severe mental illness to achieve their best level of functioning (Leff and. U. Warner, 2006). This concept brought by the recovery model can improve the outcome of the illness. Few studies suggest that employment helps people to recover from schizophrenia. Hence, with the advances in vocational rehabilitation program, the successful employment is more feasible among schizophrenic patients. In general, there are good reasons to support that employment as a vocational rehabilitation program can promote recovery among patient with schizophrenia. Work is a natural adult activity and a source of identity. Improvement in social integration,. 12.

(28) enhancement in self-identity as well as the ability of independent living is among the reasons that are required in the process of recovery provided by employment. This has shown that employment can basically improve the functional outcome in all three aspects including psychological, social and occupational functioning that are the mainstays of assessment of complete recovery. It is available of supportive evidence on the non-vocational effects of. a. employment among schizophrenia population. This non-vocational effects include the. ay. improvement of social functioning, enhanced one‘s self-image, improves quality of life and a chance to be back to the community (Leff and Warner, 2006). By participating in. al. employment and active vocational rehabilitation, it reduces the rate of rehospitalization,. M. reduces both positive and negative symptoms and as the whole, reduces the healthcare costs for schizophrenia (Bond et al., 2001). With regards to the worrying ideas that there. of. is a possibility of work increasing risk of relapses, this study found that there is no. ty. increment in the hospital admissions, symptoms, and suicide attempts when patients are. si. involved in effective work rehabilitation schemes (Bond et al. 2001). In a more recent systematic review by K Charzynska et al. 2015, with 754 studies reviewed, employment. ve r. was found promising in the improvement of the quality of life, social functioning and other indicators of recovery (K Charzynska et al. 2015).. ni. Although there is no established evidence that employment would improve. U. cognitive function, numerous studies have shown positive outcomes of employment in patients of severe mental illness. There are more robust studies reported positive effects of employment among patient with a severe mental illness that leads to achieving recovery. Employment is highly correlated with positive social, economic, health status outcomes and overall improves quality of life (HL. Provencher et al., 2002). Apart from that, employment would provide daily routine, increase social involvement, personal achievement and opportunity to improve self-confidence and the feeling of being useful. 13.

(29) to others (C. Lloyd, G. Waghorn., 2007). In the long run, stable employment reduced the risk of relapses of psychiatric illness (D. Dooley, 2003) and less frequent substance abuse (D.P. Mitchell, Betts, 2002). Hence, despite the high unemployment rate, individuals with severe mental illness mostly want to work and consider work as a critical aspect of their life and illness recovery (M. McQuilken et al., 2003). In term of recovery, there are previous studies that provide evidence on the. a. assessment of the relationship between competitive employment and recovery. A study. ay. done by Lloyd in 2010, showed that ratings on the Recovery Assessment Scale and the Community Integration Measure is positively correlated with being in employment. al. (Lloyld et al. 2010). In another more recent study that measured recovery and remission. M. outcomes as defined by Liberman et al., found that employment status was a significant predictor for recovery (Schennah et al. 2012).. of. With all the available shreds of evidence, employment has an essential role in. ty. promoting recovery among schizophrenia. Thus, as based on the recovery model, the. si. argument is on how to provide a supportive environment for the schizophrenic population in order to improve the success rate in competitive employment considering. ve r. the improvement in job attainment and retention. By having the knowledge on the factors that affecting the employment outcome, it might help the development of. ni. intervention to tackle the individual factor. One of the suggestive factors that predict the. U. success in employment is the neurocognitive deficit. However, the relationship between the success of employment and neurocognitive deficit is still being argued. Whether the employee could improve the neurocognitive deficit as a positive outcome of employment or neurocognitive deficit being the strong predictive measure of employment outcome is still inconclusive. Bio et al. in their RCT found that there is a significant improvement in executive function among clients under vocational rehabilitation (D.S. Bio, W.F. Gattaz 2011). In contrary, the more robust data are not. 14.

(30) supporting on the effect of employment on cognitive deficit. In a result of a crosssectional study showed there is no significant difference in neurocognitive measures in employed and unemployed patients (M. Tandberg, 2012). Similar with the result found by Mc Gurk et al., 2003, whereby cognitive function is stable overtime and there is no improvement despite of they participate in supported employment program. As a conclusion, the poor cognitive functioning among schizophrenic population appears. a. more likely to contribute to poor employment outcome, whereas work itself has a. ay. negligible effect on cognitive functioning (Mc Gurk, 2004). As mentioned in the previous subsection, there are more robust and establish studies to support the. al. neurocognitive deficit as the predictor of employment outcome. Thus, more studies are. M. needed to explore this relationship in order to provide better intervention and support to our schizophrenic population.. of. Cognitive deficits are the obvious and logical target of treatment in order to. ty. improve the overall functional outcome. To date, no pharmacological or psychological. si. intervention has been approved as the treatment modalities of neurocognitive deficits in schizophrenia. However, the work has been started by NIMH by introducing MATRICS. ve r. to stimulate development of medication to improve cognitive function in schizophrenic patients, and literature has shown some small improvement with atypical antipsychotics. ni. in this part of the illness (Harvey and Keefe 2001). Hence, the development of non-. U. pharmacological approaches, such as successful employment and cognitive remediation therapy may hold more promise regarding recovery. In this era, we have established evidence on the effectiveness of supported employment program as part of vocational rehabilitation that the focus is to place patients with schizophrenia in competitive employment. However, there are still many efforts required to develop effective vocational rehabilitation in order to empower the clients to achieve their best of functional level and illness recovery.. 15.

(31) 2.4 Supported employment program There are few issues related with employment among patient with schizophrenia included the job attainment and job retention. In these recent years, concern and knowledge about assisting patients with severe mental illness in employment has vastly investigated which might provide better support for the patient to acquire and retain in. a. employment.. ay. Theoretically, there are 2 approaches to the vocational rehabilitation focusing on employment which can be summarized as either, the ‗train and place‘ or ‗place and. al. train‘ approach. The older approach is based on ‗Train and place‘ concept. . This. M. concept refers to placement of the patient into prevocational training including includes general skills training, put under sheltered employment with unpaid position, which. of. prepares and trains an individual prior getting employment in the competitive market (G.. ty. Waghorn, 2010). However, the more recent study supports the greater effectiveness of. si. the supported employment program that is based on ―place and train approach‖. In this approach, it focuses on getting individuals straight to employment without prevocational. ve r. training. Supports will be provided over time after placement in the competitive job to help patients to have successful employment. Supported employment program is. ni. recognized as an evidence-based vocational rehabilitation that could improve the. U. psychological, social and occupational function of the patient with severe mental illness (Solomon P. 2009). Supported employment program is reported to be more effective than the traditional vocational program in assisting clients to obtain and retain in competitive employment (Crowther et al., 2001). Individual Placement and Support (IPS) is a refinement of the supported employment model and the most well-known form of this approach.. 16.

(32) For the past two decades, there have been more than 20 randomized controlled trials done which indicate that the individual placement and support model of supported employment is more effective than other vocational programmes at reducing unemployment (E.S. Rogers, et al., 1991). The IPS model is established by Robert Becker and Deborah Drake in the 1990s. The principles focus on evidenced-based principles including the integration of vocational and clinical services; rapid job search;. a. matching jobs to consumers' preferences and on-going job supports with the goal is to. ay. place clients in competitive employment (Bond GR et al., 2011). Competitive employment is defined as jobs in the community that pays at least minimum wages. al. (Becker, Whitely, Bailey & Drake, 2007). The majority of people with severe mental. M. illness, who enrolled under the supported employment program, achieve more competitive work in comparison to other models (Bond GR, Drake RE, Becker, 2008).. of. The outcome rate of competitive employment under supported employment was. ty. between 60% as compared to 24% of the traditional vocational program (Bond GR et al.,. si. 2008).. Specific concerns have been raised by clinician regarding Individual Placement. ve r. and Support (IPS) program especially regarding possible risks associated with higher stress at the workplace without previous lengthy training and preparatory phase. In. ni. general, stress in coping with challenging life events might precipitate illness relapses. U. and deterioration of individuals‘ mental health. However, robust data reported positive findings of IPS either in term of vocational or non-vocational outcome and became feasible in the 1990s. Available researches on the IPS program reported the most substantial evidence of its effectiveness in the non-vocational outcome. Clients who participate in this program have a lower risk of hospitalization, enhanced mental health status and life satisfaction compared to other vocational service clients (Drake et al.. 17.

(33) 2013) as well as a significantly greater decrease of depression rate than unemployed patients (Burns T et al. 2009). The IPS model is originally from the USA and has been applied in the USA successfully for more than a decade with the rate of competitive employment almost doubled compared to other forms of vocational rehabilitation. Pieces of evidence also supported the effectiveness of the IPS programme in other countries uch as Europe as. a. well as in Asian country in Hong Kong China with RCTs found the competitive. ay. employment with almost similar rate up to 55.7% of competitive employment (Bond et al 2012;Twamley,2003 ;Crowther et al,2001;Wong et al 2008). In a larger meta-analysis. al. done by Bond et al., 2012, that involved 15 RCTs of US and non-US studies on IPS. M. program, reported the difference in the percentage of competitive employment rate with studies conducted in the US showed a significantly higher rate than outside US studies. of. (62% versus 47%).. ty. It is different in the Malaysian local setting whereby most of the available work rehabilitation programme in the mental hospital is still largely following the ‗train and. si. place‘ approach by training the patients before sending them to work under sheltered. ve r. vocational rehabilitation programme. The IPS model of supported employment program was first developed in 2009 in a large scale when the resources were being channeled in. ni. placing the patients in competitive employment whereas other prevocational activities. U. were much reduced (S.H. Wan Kasim et al., 2014). In another approach other than IPS, social enterprise is also another model under. supported employment program that develop to overcome the barrier of employment among clients with severe mental illness Social enterprise involve social firm in creating a community business to provide employment opportunities, pay at regular wages in supportive, integrated and sheltered work settings (Gilbert et al., 2013). Other than these two approaches, in our local setting, there is still available of sheltered employment. 18.

(34) based on a traditional vocational approach for clients who could not survive in these two work program. In sheltered employment, the patients are placed in the transitional work for prevocational training and pay with a small number of wages. As a developing country, work rehabilitation programs in Malaysia are operating on low-resource levels as resources, in general, are inadequate in all psychiatric service setting.. a. 2.5 Job termination in supported employment program. ay. In general, scholars agreed on the effectiveness of IPS and mostly reported positive outcome of IPS with higher competitive employment rate. However, available. al. evidences might suggest that people with psychiatric disabilities have more difficulties. M. in maintaining rather than acquiring a job despite on-going job support and coaching. Studies on high fidelity IPS programme show longer employment period which is twice. of. longer (8 to 11 months) with 40% becoming steady workers over 2 years period (Bond. ty. et al., 2011), many other observers from several studies found that the job retention in. si. supported employment is fairly brief. It lasted for less than 6 months and is mostly of a part time nature (Mueser KT, et al, 2005).. ve r. Many clients under the supported employment program have difficulty achieving. their vocational goals, with at least one-third working very little or not at all and many. ni. experiencing brief job tenures with unsatisfactory job endings (T. Marshall et al., 2014).. U. Up to 52% of the 63 job terminations under the supported employment program were unsatisfactory (D. Becker et al., 1998). Unsatisfactory terminations were defined by Becker et al. in 1998 as the client quitting without having other job plans or just being fired. In another study of 108 employed adults with psychiatric disabilities receiving ongoing vocational support services, it was found that 45% were fired or quit within six month of placement due to job dissatisfaction or inability to perform the job (L.B. Gates et al., 2005).. 19.

(35) Poor working performances can be described as poor attendance and punctuality, conflicts with the supervisor, and other social and behavioral problems which figured prominently in job termination (D.C.S. Mak et al., 2006). The inability to learn to perform a job adequately may lead to poor performance reviews, in turn leading to frustration, loss of motivation, unreliable attendance, and so forth. The poor working performances are possibly related to impaired cognitive function in psychiatrically. a. disabled people. Cognitive deficits consistently predict unemployment among people. ay. with severe mental illness, including those receiving supported employment and other vocational services (Ibrahim et al., 2009). However, there is no established evidence on. al. the extent to which the cognitive deficits would contribute to the job termination.. M. Conversely, employment has been shown to improve the cognitive reserve among normal individuals (K. Anja et al. 2013). The data on the effects of employment on. of. psychiatrically disabled individuals is not well established yet. However, concern has. ty. been given to the trials on the effectiveness method to improve cognitive function and. si. hence improve the employment success. As evidenced, job tenure in supported employment programme is usually brief,. ve r. thus accommodation is needed for the patient that were enrolled in a supported employment programme in order to prolong the job tenure. Hence, assessment on job. ni. termination would be beneficial as a first step in improving employment success. One. U. potential avenue by which to improve employment success is to address the area of cognitive deficits that can impede the ability to learn job assignments and acquire other work-related skills necessary to succeed in a competitive work environment. By assessing the cognitive deficit‘s relationship to the brief job tenure, efforts can be made to accommodate the certain area of cognitive deficits in order to improve the employment success.. 20.

(36) In Malaysia, the area of employment for the patients with schizophrenia is not entirely explored. We still have a lack of local evidence on the outcome of the supported employment program in Malaysia. To our knowledge, In Malaysia, there are no studies at the moment examining the association between job terminations and cognitive deficits among supported employment clients with schizophrenia. By assessing the relationship of discrete domains of cognitive deficits to the brief job tenure, this proposed study. a. would further help in developing additional strategies designed to improve the. ay. effectiveness and cost-effectiveness of supported employment services guided by local. U. ni. ve r. si. ty. of. M. al. shreds of evidence.. 21.

(37) 2.6 Conceptual Framework Figure 2.6 Conceptual framework. Clinical factors: duration of illness, age of onset of illness. ay. a. Mediating factor. of. M. Employment outcome: working (sustain job), terminated (satisfactory vs unsatisfactory). Moderating factor. ve r. si. ty. i) Working memory ii) Processing speed iii) Reasoning and problem solving (executive. al. Deficit in specific cognitive domain:. U. ni. Sociodemographic factor: age, gender, race, religion, education, marital status Employment factor: job tenure, type of job, job preference. 22.

(38) CHAPTER 3 OBJECTIVE AND RESEARCH HYPOTHESIS. 3.1 RATIONALE OF STUDY The purpose of this study is to look for the association of specific domains of the neurocognitive deficit with the employment outcome. Job tenure in supported. a. employment is always brief and typically ends with unsatisfactory termination. Hence,. ay. by assessing neurocognitive performance in both group of clients who are able to sustain in employment and being terminated, a clearer idea can be obtained on the. al. association of cognitive function as a predictive factor of brief job tenure as well as. M. other factors associated with an employment outcome.. of. This will help to decide on better ways to accommodate and refine the supported employment concept in order to improve the job retention. It would further help in. ty. developing a better supplementary intervention to improve the supported employment. ve r. si. success that is guided by local evidence.. ni. 3.2 RESEARCH QUESTIONS. U. The following are the research questions in this study: 1). Is there any difference in the level of working memory, executive function and. speed of processing between terminated and the working group of supported employment clients with schizophrenia? 2). Are deficits in working memory, executive function and processing speed. associated with job terminations?. 23.

(39) 3). Do subjective clients‘ reasons for job termination have associations with the. presence of underlying true specific cognitive deficit?. 3.3 OBJECTIVE: General:. al. ay. among supported employment clients with schizophrenia. a. To study the association between neurocognitive function with employment outcome. M. Specific:. of. 1) To determine the difference of the level of working memory, executive function and speed of processing between the terminated and the working group of supported. ty. employment clients with schizophrenia. si. 2) To determine the association of working memory, executive function and processing. ve r. speed with job termination. ni. 3) To determine the association between clients‘ reasons for job termination with the. U. presence of an underlying true specific cognitive deficit. 24.

(40) 3.4. RESEARCH HYPOTHESIS. 1) There is a significant difference in the level of working memory, executive function and speed of processing between terminated and the working group of supported employment clients with schizophrenia 2). There is a significant association of working memory, executive function and. There is a significant association between clients‘ reasons for job termination with. ay. 3). a. processing speed with job termination. U. ni. ve r. si. ty. of. M. al. the presence of an underlying true specific cognitive deficit. 25.

(41) CHAPTER 4 METHODOLOGY. 4.1 STUDY SETTING AND STUDY PERIOD The assessment, data collection and analysis in this study were carried out from August 2018 until November 2018. Background and location of study. ay. a. This study will be conducted in Hospital Permai Johor Bahru which is at present, the second largest psychiatric hospital in Malaysia. It serves as a secondary and. al. tertiary referral centre. Hospital Permai has the most established supported employment. M. programme in Malaysia that uses the Individual Placement and Support model (IPS). The supported employment programme has been introduced in Hospital Permai. of. Johor Bahru (HPJB) since 2009. There are two models under the supported employment programme in HPJB, including the Individual Placement & Support model (IPS) and. ty. the Hybrid model (HM). IPS model has been implemented based on 7 principles by. si. Bond and Drake 1993. In the hybrid model, it is based on supported employment. ve r. principles but is being carried out in a sheltered work environment. Hence, it is also called protected competitive employment or social enterprise. This model is almost. ni. exclusively done in HPJB. Clients under social enterprise programme pay with a. U. competitive salary. However, few accommodations are provided to compensate for their difficulties with work performance and capability. For example, for clients who are unable to perform a job sufficiently alone is allowed to share the position with other clients and divide their salaries. An Occupational Therapist plays a role in managing the supported employment programme as the client‘s case manager who serves as a job coach, supervised by a medical officer and psychiatrist. Clients under this programme are usually referred from. 26.

(42) Hospital Permai, Hospital Sultanah Aminah, and Hospital Sultan Ismail. There is an average of 120 clients retained in employment each month.. 4.2. RESEARCH DESIGN This is a cross-sectional study designed on supported employment clients with. schizophrenia to look for the difference in their cognitive function based on the current. a. status of employment outcome. This study also attempted at looking for an association. ay. between specific cognitive deficits with job termination. This study was conducted in Hospital Permai. All of the subjects in this study will be selected among schizophrenic. al. patients who have enrolled under supported employment programme for at least 1. M. month (time given for job matching and attainment). The clients are divided into two groups based on their current employment status which are the terminated and working. of. groups.. ty. Both groups of subjects were assessed using sociodemographic questionnaire,. si. M.I.N.I 7.0.2 for confirmation of diagnosis and three domains of MATRICS Consensus. ve r. Battery (MCCB) including processing speed, working memory and executive function. Six cognitive tests were done to assess for each corresponding neurocognitive domain.. ni. Additional Job termination Interviews were conducted for the terminated group. The. U. time taken to complete the assessment is between 30 to 40 minutes.. 4.3. STUDY POPULATION. Adult patients aged 18-60 years, diagnosed with schizophrenia who have been enrolled under supported employment programme in Hospital Permai Johor Bahru for more than one month were invited to participate in this study. Among of these clients, only clients who had been terminated from a job for less than twelve months were. 27.

(43) selected to be in the case group. For the control group, participants were selected among clients who are able to maintain in employment for duration of more than 3 months.. 1) Terminated group: the group of client who experienced job termination within the last 12 months and are still being unemployed during the study period. This group of patients will be selected in the view that being unemployed for a longer. a. duration of 12 months in order to prevent selective bias. Being unemployed for longer. ay. than that duration would increase the risk of cognitive impairment thus would influence. al. the result in testing the difference in the cognitive level between these two groups. A. M. study done in healthy individuals on the effects of employment gaps or inactivity of six months or more was found to be associated with a higher risk of cognitive impairment. of. (A.K. Leist et al. 2013). This is due to the reduction in cognitive reserve by directly limiting opportunities for cognitively demanding activities, or indirectly via less social. ve r. si. ty. participation or lower socioeconomic status.. 2) Working group: The other group is among clients who are working and able to. ni. sustain employment for more than 3 months. The duration of 3 months is chosen as the literature found up to 45% of patient was. U. terminated within 6 months (L.B Gates et al., 2005). The control subjects who fulfil. selection criteria will be selected in the study by using convenient sampling methods. Based on statistics of the supported employment programme in Hospital Permai, there are 160 patients registered under this programme until December 2017. This number of clients includes clients who are still looking for a job, sustaining the job or being terminated from the job.. 28.

(44) Diagnosis of schizophrenia is made from clinical interview based on M.I.N.I 7.0.2. 4.3.1 Reference population All patients with the diagnosis of schizophrenia who has been enrolled under supported employment programme in Hospital Permai, Johor Bahru.. ay. a. 4.3.2 Source population All patients with the diagnosis of schizophrenia who has been enrolled under supported. al. employment programme in Hospital Permai, Johor Bahru, for at least one month during. 4.3.3 Sampling frame. of. M. the study period from August until October 2018.. ty. All patients with the diagnosis of schizophrenia who has been enrolled under supported. si. employment programme for at least one month during the study period. Among these. ve r. clients, only clients who had been terminated within the last 12 months either satisfactorily or unsatisfactorily and were still unemployed during the data collection. ni. were selected as the case group. For the control group, participants were selected among. U. clients who are able to maintain employment for duration of more than 3 months.. 4.3.4 Study sample Patients with the diagnosis of schizophrenia who has been enrolled under supported employment programme for at least one month during the study period. Among these clients, only clients who had been terminated within the last 12 months either satisfactorily or unsatisfactorily and were still unemployed during the data collection 29.

(45) were selected as the case group. For the control group, participants were selected among clients who are able to maintain employment for more than 3 months‘ duration. All of the participants were willing to take part in the study and fulfilled the selective criteria.. 4.3.4.1. Inclusion Criteria. 2. Patients aged between 18 to 60 years old.. ay. month in the supported employment programme. a. 1. Patients diagnosed with schizophrenia that have been enrolled for at least 1. al. 3. Patients must be clinically stable and not acutely psychotic. M. 4. Patients who are able to read, write and understand Malay or English. Exclusion Criteria. of. 4.3.4.2. 1. Patients have significant medical or neurological conditions that can impair. ty. cognition (e.g epilepsy, head injury, cerebral vascular disease, and dementia).. si. 2. Patients have evidence of intellectual disability. ve r. 3. Patients have co-morbid substance use disorder. ni. 4.3.5 Sampling Method. U. This study employs a convenient sampling method. Eligible candidates that consented during the study period were enrolled in the data collection until the targeted sample size was reached. The subjects were briefed about the study and the participation is on a voluntary. basis. Written consent was obtained from the subjects. Socio-demographic data of the subjects were also taken. Confidentiality is assured and no names will be attached but a coding system will be used to identify subjects.. 30.

(46) 4.3.6 Sample Size Due to time limitation, convenient sampling will be done over 4 months. A sample size of 62 participants (31 participants in each group) is needed to detect a difference in cognition between the terminated and working groups. The sample size calculation is. a. shown as below.. ay. Sample size was calculated using Power and Sample Size Calculation Programme. al. version 3.1.2 based on formula :. n = the sample size estimate. of. M. where:. ty. = SD of the variable/parameter in normal /control population (based on literature). ve r. si. µ1- µ2 or d -= detectable difference of the two means (estimates). Za= Z critical value for alpha (0.05 alpha has a Za of 1.96). U. ni. Zʙ = Z value for 1-beta (0.80 power has a Z of 0.842). In this study, we assessed three cognitive domains which are the working memory, processing speed and problem solving/executive functions. However, for the purpose of the sample size calculation, literature review on working memory will be used as it will produce the largest sample size. From a previous local study done by M Midin et. al. 2011, by using the variable of working memory (Digit Span) score in the control group (working subjects) with: Standard deviation of mean of the working group,. =2.41, 31.

(47) Difference between two means (working and terminated group) d =2.1. Using the above formula, with the ratio of 1:1 of the terminated and working groups, sample size (N)=22 patients in each arm. The calculation for sample size also takes into account an average dropout rate of 9% in IPS as well as departmental statistics in the Occupational Therapy Unit that sees a dropout rate of 20%.. a. With the addition of possible dropout rate of 40%, an additional 9 patients each arm, it. ay. brings the number to 31 participants per group. A 40% dropout rate is assumed to ensure that the study still has adequate power, should there be many participants who. 4.4 RESEARCH TOOLS. ty. 4.4.1 Neurocognitive test. of. M. participants were recruited in this study.. al. drop out from the study. This gives us a sample size of 62. Hence, a total of 62. si. The National Institute of Mental Health‘s (NIMH) Measurement and Treatment. ve r. Research to Improve Cognition in Schizophrenia (MATRICS) developed a consensus battery for clinical trial of cognition-enhancing treatments for schizophrenia. The. ni. MCCB has shown good reliability, practicability and good relationship to functional. U. status (Nuechterlein et al., 2008). It consists of 10 tests that combine into 7 cognitive domains including i) Working memory : -. Wechsler Memory Scale-Third Edition (WMS-III): Spatial Span. -. Wechsler Memory Scale-Third Edition (WMS-III): Letter-Number Span. ii) Processing speed: -. Brief Assessment Of Cognition In Schizophrenia (BACS) – Category Fluency 32.

(48) -. BACS – Symbol Coding. -. Trail Making Test-A. iii) Reasoning and problem solving -. Neuropsychological Assessment Battery (Nab) – Mazes. iv) Attention Continuous Performance Test—Identical Pairs (CPT-IP). a. -. -. ay. v) Verbal learning. Hopkins Verbal Learning Test-Revised (HVLT-R). Brief Visuospatial Memory Test-Revised. M. -. al. vi) Visual learning. vii) Social cognition. Mayer-Salovey-Caruso Emotional Intelligence Test (MSEIT):Managing. ty. Emotions. of. -. si. However, in this study, only three cognitive domains that consisted of 6 tests were. U. ni. ve r. assessed. The description of each test is explained as below.. 33.

(49) Domain to be Test. Description. Tested SPEED. OF BRIEF ASSESSMENT OF. Name of animals are tested for 60. PREOCESSING COGNITION IN. seconds with score for number of. SCHIZOPHRENIA (BACS). animals named.. – CATEGORY FLUENCY Symbols were coded with numbers. CODING. and the numbers of symbols matched. a. BACS – SYMBOL. ay. to numbers were obtained for 90 seconds.. Paper-and-pencil test in which a line. al. TRAIL MAKING TEST-A. M. to connect the numbered dots placed irregularly on a sheet of paper is. of. timed.. WECHSLER. MEMORY. SCALE-THIRD. MEMORY Tapping cubes irregularly placed on EDITION a board in the correct sequence.. ty. WORKING. (WMS-III):. ve r. si. SPAN. U. ni. WECHSLER. SPATIAL Number of correct sequence is scored.. MEMORY Orally administered test in which. SCALE-THIRD. EDITION participant rearranges a string of. (WMS-III):. LETTER- number and letters.. NUMBER SPAN. REASONING. NEUROPSYCHOLOGICAL Participants solve 7 mazes, with. AND. ASSESSMENT BATTERY increasing. PROBLEM. (NAB) – MAZES. SOLVING. difficulty.. Points. are. awarded based on the time used to solve the maze.. (EXECUTIVE FUNCTION). 34.

(50) MCCB was bought by Badan Pendidikan Psikiatri, Hospital Permai for research purposes. I was trained by researchers and clinicians that had used the MCCB previously and were trained by the developers. While MCCB has been shown to have good tolerability in its original English form, there are concerns regarding its use in the local setting as our primary language is. a. Malay. Therefore, in this study only three domains were assessed so that the. ay. components of the tests pose no problem regardless of the language used. All the tests that will be done only require verbal instruction to be given in the familiar language.. al. These three domains are important domains that are found to affect the functional. M. recovery. The domains include working memory, problem solving/executive function and speed of processing. All the tests under each domain will be done; processing. of. speed: Brief Assessment of Cognition in Schizophrenia (BACS) – Category Fluency,. ty. symbol coding and Trail Making Test; working memory: Wechsler Memory ScaleThird Edition (WMS-III): Letter-Number Span and spatial span; problem solving:. ve r. si. Neuropsychological Assessment Battery (NAB) – Mazes as described above. The results from the tests will be written as raw score in the MCCB Scoring. ni. Programme and T Score for each domain will be generated by the programme and. U. collected as the data. However, no composite t score will be produced as only three out of 7 cognitive domains were assessed. The normal value for the T score is 50 ± 10 for each of the 7 domains. Those participants who score below the normal range is considered to have cognitive deficit (Kern et al., 2008). The time taken to do all assessments is 30 to 40 minutes. The testing will be. done by one interviewer (researcher). Blinding of the rater could not be done in this study in view that the terminated group were assessed for Job Termination Interview. 35.

(51) (JTI) by the same interviewer. All the assessments will be done during the participants‘ scheduled outpatient clinic visits or home visits. 4.4.2 Mini International Neuropsychiatric Interview (MINI) 7.0.2 Mini International Neuropsychiatric Interview (MINI) is a brief, structured diagnostic interview developed for the major psychiatric disorder in DSM 5 and ICD 10. With an administration time of approximately 15 minutes, the MINI is the structured psychiatric. a. interview of choice for psychiatric evaluation and outcome tracking in clinical. ay. psychopharmacology trials and epidemiological studies. This instrument is used to. Job Termination Interview (JTI). of. 4.4.3. M. al. confirm the diagnosis of schizophrenia by using Module K in M.I.N.I 7.0.2. It is an instrument that was developed for psychiatrically disabled clients to. ty. assess the job termination. The questions include the type of termination, reasons for. si. termination, and needed job accommodations. Reasons for termination on the JTI were. ve r. coded present or absent in ten categories: mental illness, anxiety unrelated to mental illness, medical problem, substance abuse, dependability, work quality, interpersonal. ni. difficulty, dissatisfaction with job, fear of losing benefits, and others.. U. Job terminations were classified as satisfactory (left for another job, laid off due. to elimination of the job, or left because the job was time-limited) or unsatisfactory (fired or left without another job) (D.R. Becker et al in 1998).. 36.

(52) 4.4.4 Socio-demographic, Employment and clinical data Socio-demographic, Employment and Clinical data were collected as baseline. Socio-demographic data: Age, gender, race and educational level were obtained to ensure an equally distributed population. Employment data: Baseline data of employment status (working vs terminated), job tenure, duration of unemployment and types of job. Clinical data: Clinical data were obtained from patient and case notes included age of. ay on. Mini. International. Neuropsychiatric. M. Based. al. 4.5 Operational Criteria Schizophrenia. a. onset and duration of illness were also obtained.. Interview (M.I.N.I) version 7.0.2 questionnaire The result of the test for each domains will be. of. Working Memory. by computer software. of. MATRICS. ty. calculated. Executive Function. si. Consensus Cognitive Battery (MCCB) and generate a. ni. ve r. Speed of Processing. U. Type of job. score A score of below 40 for each domains is considered as presence of deficit Professional and administration/clerical/sales/service/ manual labour. Past work history. Duration of previous work in months. Employment outcome. Terminated: clients with schizophrenia under supported employment programme who are already terminated within the last 12 months and still being unemployed during the assessment. 37.