Prognostic impact of psychoeducation program completion on inpatients with schizophrenia: a pilot cohort study

Prognostic impact of psychoeducation program completion on inpatients with schizophrenia: a pilot cohort study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prognostic impact of psychoeducation program completion on inpatients with schizophrenia: a pilot cohort study Hiroki Noguchi, Seiichiro Tarutani, Yoshiki Takei, Koichi Matsumoto, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4868072/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Jan, 2025 Read the published version in BMC Psychiatry → Version 1 posted 13 You are reading this latest preprint version Abstract Background Psychoeducation programs can reduce the risk of recurrence and readmission in patients with schizophrenia. However, almost all previous studies of program efficacy have included only patients completing the program, which may not be possible in all cases. The objective of this pilot cohort study was to compare the prognoses of inpatients with schizophrenia who did or did not complete a well-established institutional psychoeducation program. Methods This study is a pilot cohort study, and the participants were 32 inpatients in the psychiatric acute care ward. Among these patients, 18 completed the institutional psychoeducation program by discharge, whereas 14 missed one or more sessions for various reasons. The primary outcome was the duration of outpatient treatment (DOT) during the 5-year follow-up period, and the secondary outcomes were comparisons of the risk of all-cause discontinuation for outpatient treatment and correlations between the program participation rate and DOT. Results DOT was significantly longer in the program completion group than in the noncompletion group (918.2 (174.3) days vs. 225.5 (35.7) days, p = 0.001), and Cox proportional hazards regression analysis revealed that program noncompliance was associated with a 4.089-fold ( p = 0.002) greater risk of discontinuation of outpatient treatment according to univariate analysis and a 2.937-fold ( p = 0.030) greater risk according to multivariate analysis. A significant weak correlation was found for DOT and rates of sessions admitted to the programme (Pearson's r = 0.384, p = 0.030). Conclusions Completion of a psychoeducation program dramatically enhanced the success of outpatient treatment. Because of the significant impact of outpatient treatment on prognosis, inpatient psychoeducation programs should be sufficiently flexible to provide opportunities for completion. schizophrenia psychoeducation completion duration of outpatient treatment (DOT) Figures Figure 1 Figure 2 Figure 3 Introduction Schizophrenia is a severe chronic mental disorder characterized by heterogeneous clusters of behavioral, emotional, and cognitive symptoms that are frequently intractable to current psychiatric therapies. As a result, patients require long-term monitoring and pharmacotherapy, including antipsychotic drugs, to improve symptoms and prevent recurrence. In addition, outpatients with schizophrenia experience many additional life challenges, including poor family support, problems with interpersonal relationships, difficulty finding employment, poverty, and side effects of medication that lead to poor treatment adherence [ 1 ]. Inpatient care and outpatient management must include interventions that can improve general social functioning. Several studies have reported that inpatients receiving psychoeducation demonstrate better treatment adherence and lower recurrence rates in the short-term and medium- to long-term[ 2 , 3 ]. Therefore, greater access to effective psychoeducation programs may reduce readmission rates, improve outpatient quality of life (QOL), and lessen the burden on patients with schizophrenia. However, almost all previous studies on the efficacy of psychoeducation have included only patients completing the program; thus, how noncompletion affects patient prognosis is currently unknown. It has also proven difficult in such studies to closely monitor changes in the psychiatric condition of discharged patients and evaluate the ways in which psychoeducation is used in daily life. Moreover, concrete and common criteria for recurrence or readmission have not been specified in many previous studies [ 4 , 5 ], but interruptions in social life, including hospitalization, may be traumatic regardless of the reason. Shin-Abuyama hospital offers a psychoeducation program for inpatients aimed at preventing recurrence and readmission for schizophrenia, similar to many other psychiatric institutions. However, in the real-world clinical setting, unlike in research fields, a certain percentage (sometimes approximately half) of patients were unable to complete the program owing to early discharge or other treatment schedules. Therefore, it is an urgent task to clarify how the completion or noncompletion of psychoeducation programs affects the long-term prognosis of patients, but to the best of our knowledge, there are no such previous studies. Thus, this study aimed to clarify how the completion or noncompletion of a psychoeducation program affects all-cause discontinuation in outpatient treatment over a 5-year follow-up period after discharge via a single-center pilot cohort study. Methods Study design This is a pilot prospective observational cohort study conducted at the psychiatric acute care ward of Shin-Abuyama Hospital, Osaka Institute of Clinical Psychiatry, Osaka, Japan, from 1st August 2016 to 31st July 2017. Selection of study participants Study participants were recruited as follows. First, potential participants were selected by two or more registered nurses responsible for administering the psychoeducation program. Among the selected patients, the attending psychiatrist made the final decision about participation according to the following criteria: 1) a low risk of self-harm or harm due to psychiatric symptoms; 2) sufficient verbal communication skills; and 3) the ability to pay attention during the 60-minute session. Second, eligible participants were selected from among the program participants who met the following inclusion criteria: 1) had a diagnosis of schizophrenia (F20) according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Edition (ICD-10) [ 6 ]; 2) were admitted to the acute psychiatric ward of Shin-Abuyama Hospital during the study period; 3) participated in a psychoeducation program for inpatients from the first session; and 4) were able to provide informed consent. The exclusion criteria were as follows: 1) diagnosis of a cooccurring psychiatric disorder, 2) never attended a psychoeducational session, 3) failure to be discharged after the program, or 4) withdrawal of consent. We defined participants who attended all sessions as the program completion group (CG) and those who missed one or more, albeit not all, sessions as the program non-completion group (NG). Psychoeducation program for inpatients The psychoeducation program for inpatients at Shin-Abuyama Hospital consists of five semistructured group sessions (Table 1 ) based on the Japanese Psychoeducation Promotion Guidelines toolkit [ 7 , 8 ]. All five sessions were set up by different experts, and the importance of different interventions was the focus of the lectures. Session 1 was conducted by a psychiatrist, Session 2 by an occupational therapist, Session 3 by a mental health worker, Session 4 by a pharmacist, and Session 5 by a nurse. In addition, two or three nurses attended all the sessions as coleaders. Variables Participant characteristics Age, sex, age of onset (first episode), duration (years) of illness, type of hospitalization (involuntary admission or not), duration (days) of hospitalization in the psychiatric acute care ward, chlorpromazine equivalent dose of antipsychotic medication [ 9 ], and Global Assessment of Functioning (GAF) scores [ 10 , 11 ] were collected from medical records. Outcome The primary outcome in this study was the duration of outpatient treatment (DOT) [ 12 ]. We defined the day of discharge as day 0 and the day of all-cause discontinuation of outpatient treatment (e.g., readmission, recurrence, suicide, or interruption of regular outpatient hospital visits) as the DOT end day. All participants were followed up for 5 years (1825 days) after discharge via medical records and, if there was difficulty, by phone. In cases where the defining event for DOT could not be determined precisely, we defined the day after the last outpatient visit as censoring and used it for the analysis. The secondary outcomes were 1) comparative risk (hazard ratio) of all-cause discontinuation of outpatient treatment, 2) the proportion of events precipitating DOT ending each year after discharge, 3) the correlation of DOT with the rates of psychoeducation sessions attended, and 4) changes in QOL dimension scores after the program compared with baseline. We adopted the Japanese version of the Schizophrenia Quality of Life Scale (J-SQLS) as an index of QOL. The J-SQLS is a disease-specific subjective QOL rating scale [ 13 , 14 ] used here as an alternative index of the effect of inpatient treatment. This scale consists of three subscales: “motivation/energy” (ME), “psychological/social relations” (PS), and “symptoms/side effects” (SS). The J-SQLS was administered both before and after the psychoeducation program, and raw scores and subscores, as well as changes in scores and subscores after the intervention, were compared within groups and between the CG and NG. Study size calculations Since no previous studies exist, hazard ratios were assumed, and sample sizes were calculated on the basis of clinical realities. A hazard ratio of 0.3 between the CG and NG, an allocation ratio of 1:1, a study period of 1 year, a follow-up period of 5 years, a log-rank test, 80% statistical power, and a type I error rate of p = 0.05 were adopted, and the sample size was calculated to be 14 participants per group, for a total of 28 participants [ 15 , 16 ]. To eliminate the possibility of sampling bias, we attempted to recruit as many participants as possible within the study period. Statistical analysis Statistical analyses were performed via SPSS Statistics version 27 (IBM Corp., Armonk, NY, USA). Patient age, age of onset (first episode), duration (years) of illness, duration (days) of hospitalization in the psychiatric acute care ward, GAF score, J-SQLS score, and chlorpromazine equivalent dose in the psychiatric acute care ward were compared between groups by Student’s t test or Welch’s t test, as indicated, after verifying homoscedasticity. The proportions of sex and type of hospitalization (involuntary admission or not) were compared via Fisher’s exact test. DOT was analyzed via the Kaplan–Meier method and compared between groups via the log-rank test. The hazard ratio for the differential risk of discontinuation of outpatient treatment during follow-up was calculated via the Cox proportional hazard regression model. Cox proportional hazards regression analysis was performed via univariate regression analysis with the following basic variables: age, sex, age of onset, duration of illness, type of admission, chlorpromazine equivalent dose, GAF before the program, J-SQLS subscores (ME, PS, and SS) before the program, completion of the program, and rates of session attended as independent variables. Multivariate analyses were conducted using the independent variables that each showed significant differences (p < 0.05) in the univariate regression analysis. Disruption event occurrence rates for each year were compared via Fisher's exact test because fewer than five such events occurred during each year. Correlations between DOT and the number of sessions attended were analyzed via Pearson’s method. For the J-SQLS subscores, independent t tests were used before the program, after the program, and after the program, and between-group comparisons were performed. Paired t tests were used for before/after comparisons and within-group comparisons. All the statistical comparisons were two-tailed, and the statistical significance level was set at p = 0.05. In the case of missing values, those values were excluded, and only the obtained data were analyzed. Ethical considerations This study was conducted with the approval of the Institutional Review Board of Shin-Abuyama Hospital (2016-1) and conformed to the requirements of the latest version of the Declaration of Helsinki. The following ethical considerations were incorporated into the study design, enrollment criteria, follow-up, and analysis: primacy of individual patient wishes, guarantee against therapeutic disadvantages, freedom to withdraw consent, protection of personal data, purpose of use, and disposal of personal data. All participants provided their written consent after receiving a full explanation of the study procedures and patient rights. Results Participant characteristics A total of 72 patients with schizophrenia were admitted to the ward during the study period, 61 of whom met the eligibility criteria. Of these, 38 participated in the program, 33 of whom consented to the study. Furthermore, of these 33 participants, one was excluded because of withdrawal of consent. Among the 32 eligible participants, 18 were CGs, and 14 were NGs and were followed for up to 5 years. One CG participant was censored 4 years after discharge (day 1543) because of untraceability after changing doctors due to relocation and changing doctors and phone numbers again, resulting in a final sample of 17 CG and 14 NG participants (Fig. 1 ). Of the 32 inpatients enrolled in the study, 18 completed the psychoeducation program (CG), and 14 did not (NG) (Table 2 ). There were no significant group differences (CG vs. NG) in age, sex ratio, age of onset (first episode), duration (years) of illness, type of hospitalization (involuntary admission or not), duration (days) of hospitalization in the psychiatric acute care ward, chlorpromazine equivalent dose, or GAF score (Table 2 ). Program attendance, DOT and events by participants are summarized in Table 3 . Primary outcome (DOT) The final analysis included 18 CG and 14 NG participants. Survival analysis revealed significantly longer DOT in the remaining CG patients than in the remaining NG patients (918.2 (174.3) days, 95% CI: 576.7–1259.8 vs. 225.5 (35.7) days, 95% CI: 155.5–295.5; p = 0.001 by log-rank test) (Fig. 2 ). Secondary outcomes Cox proportional hazard regression analysis using univariate analysis with the characteristic variables as independent variables revealed significant differences in age at onset (HR = 0.921, p = 0.021), duration (years) of illness (HR = 1.070, p = 0.003), PS of the J-SQLS subscore (HR = 0.975, p = 0.037) and program completion (HR = 4.089, p = 0.002). Multivariate analysis using age of onset, duration (years) of illness, the PS of the J-SQLS subscore, and program completion as independent variables revealed a significant difference in program completion (HR = 2.937, p = 0.030). Patients who did not complete the study were at 2.937-fold greater risk of all-cause discontinuation of outpatient treatment than patients who attended all sessions (Table 4 ). For all participants, discontinuation of outpatient treatment was attributed to “readmission due to recurrence” (Table 3 ). The cumulative number of readmissions was significantly greater among program non-completers than among program completers by the end of each follow-up year (Table 5 ). There was a significantly weak correlation between DOT and the number of sessions attended (Pearson's r = 0.384, p = 0.030, 95% CI: 0.001–0.646) (Fig. 3 ). Between-group comparisons before the program, after the program, and changes in the J-SQLS subscores revealed no significant differences in any of the subscores (CG vs. NG). However, within-group comparisons revealed significant improvements in the “psychological/social relations (PS)” subscale of the CG and no significant differences in the other subscales (Table 6 ). Discussion To the best of our knowledge, this is the first study comparing the long-term (5 years) efficacy of inpatient psychoeducation for schizophrenia management after hospital release between participants attending all sessions and participants missing one or more (but not all) sessions. Indeed, this is possibly the first pilot cohort study to examine the prognostic impact of the frequency of psychoeducation participation in a small but real-world setting. Therefore, the NG demonstrated an approximately 2.9-fold greater risk of all-cause discontinuation of outpatient treatment as well as earlier readmission for disease relapse. Furthermore, a comparison of subjective QOL at the end of acute psychiatric treatment also revealed a significant improvement in psychological and social QOL among the CG. Thus, program completion improved outcomes in both the short and long term. The results of this study are consistent with those of a previous study in the short term [ 17 ]. Similarly, a recent meta-analysis concluded that complete psychoeducation reduced the recurrence/readmission rate among patients with schizophrenia spectrum disorders in the acute phase [ 18 ]. Furthermore, these interventions had similar preconditions as those of the current study. It is therefore essential that such programs be delivered with sufficient flexibility to allow completion by all inpatients. Robinson et al. [ 19 ] reported that more than half of patients with schizophrenic disorders (63.1%) relapsed within 3 years after the first hospitalization, a rate similar to that of our CG. In contrast, all patients who did not complete the psychoeducation program relapsed within 2 years of discharge. Patients with poor medication adherence as outpatients are 2.4 times more likely to be rehospitalized than those with good medication adherence, and nonadherence is the major cause of relapse or recurrence [ 20 , 21 ]. The lower recurrence rate among patients completing our psychoeducation program cannot be explained by the characteristics of the participants in the NG (Table 2 ); however, the study suggests that the program may have contributed to improved medication adherence. The efficacy of psychoeducation for preventing recurrence has been verified by multiple studies [ 2 , 3 , 22 ]. In addition, psychoeducation was reported to improve patient QOL [ 23 ]. Similarly, the program described here also improved the “PS relations” domain of the J-SQLS, suggesting that inpatient treatment, including the program, is more effective than treatment without program completion and potentially provides better preparation for outpatient function. There are several distinct models of psychoeducation for patients with schizophrenia, such as programs including the participation of families as well as patients [ 24 ], programs delivered exclusively for outpatients or continuing in an outpatient setting [ 25 ], and community-based programs [ 23 ]. Programs adopting a combination of educational, behavioral, and emotional strategies are highly effective at maintaining medication adherence and reducing recurrence and readmission [ 26 ], whereas psychoeducational interventions without behavioral elements or support services may not be as effective [ 27 , 28 ]. In this study, the target, method, frequency, and environment of the intervention differed from those of the aforementioned studies; thus, it is difficult to fully explain the comparison of efficacy rates and the reason for prolonged DOT. Nonetheless, completion of these programs appears essential for full efficacy [ 17 ]. The only clear difference between completers and noncompleters is the amount of knowledge acquired [ 29 ], but a causal relationship between the amount of knowledge and recurrence risk has not been demonstrated. Similarly, while poor medication adherence is strongly associated with recurrence [ 30 ], no causal relationship has been established between the contents of psychoeducation and adherence. The multiaxial approach to psychoeducation programs by five professions (psychiatrists, occupational therapists, mental health workers, pharmacists and nurses) may have influenced the results of this study and further confirmed a possible correlation between the rates of sessions attended and DOT. These findings strongly support the hypothesis that the completion of psychoeducation programs is essential for relapse prevention and suggest that more program attendance improves outpatient outcomes. In the future, expanding the sample size and further analyzing the relationship between missed content and recurrence may be useful in developing and improving psychoeducation programs. Limitations This study is a pilot study; however, owing to the small sample size, a larger (possibly multicenter) study is warranted. One of the other potential confounders is differences in delivery among leaders of the psychoeducation program. Although our psychoeducation program was created on the basis of a toolkit, there is no nation-wide program in Japan for training psychoeducation practitioners. There are also major differences in program content and emphasis (e.g., number of sessions) among centers. To solve this problem, establishing a standardized program and supervision system to ensure the homogeneity of the program's effectiveness are essential. Next, there are marked differences in cognitive abilities among patients, further compounding heterogeneity in the outcome within and among treatment centers. Although there was no statistically significant difference in the GAF score between the completion and noncompletion groups, it has been reported that disease severity can hinder program completion. More vulnerable patients may not be able to fully learn and use the coping strategies included in the program to prevent recurrence [ 31 ]. Such cases may require more pervasive monitoring rather than relying on the benefits of psychoeducation. It is also critical to identify and validate the most therapeutically effective elements of the program for emphasis, especially for cases with limited cognitive capacity. Finally, we were not able to verify whether the prognosis improved as a result of the completion of psychoeducation and adherence to medication or whether the prognosis improved as a result of improved attitudes toward medication or insight into the disease due to the completion of psychoeducation. To solve this problem, additional studies that include assessments of personality and cognitive function would be appropriate. Future perspective It has been reported that medication adherence may decrease with time following schizophrenia diagnosis [ 12 ], whereas the risk of death may increase [ 32 ]. These findings suggest that interventions aimed at improving adherence should instead be instituted or repeated during this critical period. There is also evidence that psychoeducation is not effective for patients at onset [ 33 ]. Therefore, first hospitalization is an appropriate time for psychoeducation despite challenges in some cases, such as early release or poor patient condition. Future studies should expand the sample size to examine how program completion is related to DOT, along with attitudes toward medication, insight into the disease and medication adherence. Conclusion Noncompletion of an inpatient psychoeducation program resulted in a significantly shorter duration of uninterrupted outpatient treatment and earlier symptom recurrence. These results suggest that the completion of psychoeducation programs has a strong positive effect on patient prognosis. All efforts should be made to allow inpatients the opportunity to complete psychoeducation programs as early as possible after the onset of illness despite time constraints and other challenges to prevent relapse or recurrence. Abbreviations CG; completion group DOT; duration of outpatient treatment GAF; Global Assessment of Functioning J-SQLS; Japanese version of the Schizophrenia Quality of Life Scale NG; noncompletion group QOL; quality of life Declarations Ethics approval statement This study was conducted with the approval of the Institutional Review Board of Shin-Abuyama Hospital (2016-1) and conformed to the requirements of the latest version of the Declaration of Helsinki. Consent to participate All the participants provided written consent after being fully informed of the study procedures and patient rights. Consent for publication All the participants provided written consent after being fully informed of the study procedures and patient rights. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests Hiroki Noguchi, Yoshiki Takei, Koichi Matsumoto, and Hiroshi Yoneda declare no competing interests relevant to the publication of this study. Seiichiro Tarutani has received consulting fees from Janssen Pharmaceutical K.K. and honoraria for lectures from Otsuka Pharmaceutical Co. Ltd., Sumitomo Pharma Co. Ltd., Mochida Pharmaceutical Co. Ltd., Shionogi Pharma Co. Ltd., Viatris Inc., Janssen Pharmaceutical K.K., and Yoshitomiyakuhin Co. Takehiko Okamura has received consulting fees from Otsuka Pharmaceutical Co. Ltd. and honoraria for lectures from Otsuka Pharmaceutical Co. Ltd., Sumitomo Dainippon Pharma Co. Ltd., and Janssen Pharmaceutical K.K. Funding Not applicable. Authors’ contributions Conceptualization, H.N. and S.T.; Data curation, H.N. and S.T.; Formal analysis, S.T.; Funding acquisition, S.T.; Investigation, H.N. and S.T.; Methodology, S.T.; Project administration, H.N. and S.T.; Resources, S.T.; Software, S.T.; Supervision, S.T., T.O. and H.Y.; Validation, S.T.; Visualization, H.N., S.T. Y.T. and K.M.; Writing – original draft, H.N. and S.T.; Writing – review & editing, S.T. and T.O. Acknowledgments We would like to thank the medical staff of the psychiatric acute care ward (especially Tamami Yamasaki, Kanako Koizumi, Tomoko Kobatake, Kanpei Nakanishi and Ryoichi Ueno) and colleagues in the medical care office at Shin-Abuyama Hospital for their cooperation in this study. Clinical Trial Registration Not applicable. References Xiao J, Mi W, Li L, Shi Y, Zhang H. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4868072","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":347904165,"identity":"1a816d47-6b9e-419c-b387-c082350984e3","order_by":0,"name":"Hiroki Noguchi","email":"","orcid":"","institution":"Shin-Abuyama Hospital, Osaka Institute of Clinical Psychiatry","correspondingAuthor":false,"prefix":"","firstName":"Hiroki","middleName":"","lastName":"Noguchi","suffix":""},{"id":347904166,"identity":"082c053c-1576-4898-8a24-3aa572135edd","order_by":1,"name":"Seiichiro Tarutani","email":"data:image/png;base64,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","orcid":"","institution":"Shin-Abuyama Hospital, Osaka Institute of Clinical Psychiatry","correspondingAuthor":true,"prefix":"","firstName":"Seiichiro","middleName":"","lastName":"Tarutani","suffix":""},{"id":347904167,"identity":"ce07112e-f222-44ab-a815-3c04b188758a","order_by":2,"name":"Yoshiki Takei","email":"","orcid":"","institution":"Osaka Medical and Pharmaceutical University","correspondingAuthor":false,"prefix":"","firstName":"Yoshiki","middleName":"","lastName":"Takei","suffix":""},{"id":347904168,"identity":"7dc365ef-3040-4649-b926-eb518f6e0a16","order_by":3,"name":"Koichi Matsumoto","email":"","orcid":"","institution":"Osaka Medical and Pharmaceutical University","correspondingAuthor":false,"prefix":"","firstName":"Koichi","middleName":"","lastName":"Matsumoto","suffix":""},{"id":347904169,"identity":"414becb1-5897-46b5-9bdc-7d8a00c49e99","order_by":4,"name":"Takehiko Okamura","email":"","orcid":"","institution":"Shin-Abuyama Hospital, Osaka Institute of Clinical Psychiatry","correspondingAuthor":false,"prefix":"","firstName":"Takehiko","middleName":"","lastName":"Okamura","suffix":""},{"id":347904170,"identity":"1820acd4-1395-4978-91c2-2caf945a5119","order_by":5,"name":"Hiroshi Yoneda","email":"","orcid":"","institution":"Shin-Abuyama Hospital, Osaka Institute of Clinical Psychiatry","correspondingAuthor":false,"prefix":"","firstName":"Hiroshi","middleName":"","lastName":"Yoneda","suffix":""}],"badges":[],"createdAt":"2024-08-06 11:21:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4868072/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4868072/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12888-024-06397-5","type":"published","date":"2025-01-17T15:57:11+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":64321093,"identity":"870db435-7a1d-4150-8e37-29ab8790fdec","added_by":"auto","created_at":"2024-09-11 15:26:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":551226,"visible":true,"origin":"","legend":"\u003cp\u003eThe STROBE study flow chart.\u003c/p\u003e\n\u003cp\u003eSTROBE, Strengthening the Reporting of Observational Studies in Epidemiology. CG: program completion group, NG: program noncompletion group.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4868072/v1/ca9e475f216bc9e9560be324.png"},{"id":64320026,"identity":"587f6378-ad8f-49b7-b1d6-71ed3ce9c3a1","added_by":"auto","created_at":"2024-09-11 15:18:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":52703,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan–Meier survival curves for the duration of outpatient treatment in the completion and non-completion groups.\u003c/p\u003e\n\u003cp\u003eCG: 918.2 (174.3) days, 95%CI: 576.7–1259.8 vs. NG: 225.5 (35.7) days, 95%CI: 155.5–295.5; \u003cem\u003ep\u003c/em\u003e = 0.001 (log-rank test).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4868072/v1/c6f240f32fdf29ff7703e244.png"},{"id":64320027,"identity":"1aae2af0-db1b-484e-abe6-56932ae4db88","added_by":"auto","created_at":"2024-09-11 15:18:29","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":50213,"visible":true,"origin":"","legend":"\u003cp\u003eCorrelation between DOT and rates of sessions of the psychoeducation program attended.\u003c/p\u003e\n\u003cp\u003ePearson’s \u003cem\u003er\u003c/em\u003e = 0.384, \u003cem\u003ep\u003c/em\u003e = 0.030 (95%CI: 0.001–0.646), R2 linear = 0.147\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4868072/v1/b7277658eb5ec8f555689c18.png"},{"id":74284738,"identity":"fe54ed6e-5667-489f-9fef-3991c1b43fb6","added_by":"auto","created_at":"2025-01-20 16:12:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1273557,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4868072/v1/7909ae85-9c20-419c-8307-6065c9a1fc77.pdf"},{"id":64320029,"identity":"55e042a3-bd2b-4412-b983-2babbf75b7bc","added_by":"auto","created_at":"2024-09-11 15:18:29","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":642801,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-4868072/v1/68a748fb5b07269786ce4f4a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prognostic impact of psychoeducation program completion on inpatients with schizophrenia: a pilot cohort study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSchizophrenia is a severe chronic mental disorder characterized by heterogeneous clusters of behavioral, emotional, and cognitive symptoms that are frequently intractable to current psychiatric therapies. As a result, patients require long-term monitoring and pharmacotherapy, including antipsychotic drugs, to improve symptoms and prevent recurrence. In addition, outpatients with schizophrenia experience many additional life challenges, including poor family support, problems with interpersonal relationships, difficulty finding employment, poverty, and side effects of medication that lead to poor treatment adherence [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Inpatient care and outpatient management must include interventions that can improve general social functioning. Several studies have reported that inpatients receiving psychoeducation demonstrate better treatment adherence and lower recurrence rates in the short-term and medium- to long-term[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, greater access to effective psychoeducation programs may reduce readmission rates, improve outpatient quality of life (QOL), and lessen the burden on patients with schizophrenia.\u003c/p\u003e \u003cp\u003eHowever, almost all previous studies on the efficacy of psychoeducation have included only patients completing the program; thus, how noncompletion affects patient prognosis is currently unknown. It has also proven difficult in such studies to closely monitor changes in the psychiatric condition of discharged patients and evaluate the ways in which psychoeducation is used in daily life. Moreover, concrete and common criteria for recurrence or readmission have not been specified in many previous studies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], but interruptions in social life, including hospitalization, may be traumatic regardless of the reason.\u003c/p\u003e \u003cp\u003eShin-Abuyama hospital offers a psychoeducation program for inpatients aimed at preventing recurrence and readmission for schizophrenia, similar to many other psychiatric institutions. However, in the real-world clinical setting, unlike in research fields, a certain percentage (sometimes approximately half) of patients were unable to complete the program owing to early discharge or other treatment schedules.\u003c/p\u003e \u003cp\u003eTherefore, it is an urgent task to clarify how the completion or noncompletion of psychoeducation programs affects the long-term prognosis of patients, but to the best of our knowledge, there are no such previous studies.\u003c/p\u003e \u003cp\u003eThus, this study aimed to clarify how the completion or noncompletion of a psychoeducation program affects all-cause discontinuation in outpatient treatment over a 5-year follow-up period after discharge via a single-center pilot cohort study.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy design\u003c/h2\u003e\n \u003cp\u003eThis is a pilot prospective observational cohort study conducted at the psychiatric acute care ward of Shin-Abuyama Hospital, Osaka Institute of Clinical Psychiatry, Osaka, Japan, from 1st August 2016 to 31st July 2017.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eSelection of study participants\u003c/h2\u003e\n \u003cp\u003eStudy participants were recruited as follows. First, potential participants were selected by two or more registered nurses responsible for administering the psychoeducation program. Among the selected patients, the attending psychiatrist made the final decision about participation according to the following criteria: 1) a low risk of self-harm or harm due to psychiatric symptoms; 2) sufficient verbal communication skills; and 3) the ability to pay attention during the 60-minute session.\u003c/p\u003e\n \u003cp\u003eSecond, eligible participants were selected from among the program participants who met the following inclusion criteria: 1) had a diagnosis of schizophrenia (F20) according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Edition (ICD-10) [\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e]; 2) were admitted to the acute psychiatric ward of Shin-Abuyama Hospital during the study period; 3) participated in a psychoeducation program for inpatients from the first session; and 4) were able to provide informed consent.\u003c/p\u003e\n \u003cp\u003eThe exclusion criteria were as follows: 1) diagnosis of a cooccurring psychiatric disorder, 2) never attended a psychoeducational session, 3) failure to be discharged after the program, or 4) withdrawal of consent.\u003c/p\u003e\n \u003cp\u003eWe defined participants who attended all sessions as the program completion group (CG) and those who missed one or more, albeit not all, sessions as the program non-completion group (NG).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003ePsychoeducation program for inpatients\u003c/h2\u003e\n \u003cp\u003eThe psychoeducation program for inpatients at Shin-Abuyama Hospital consists of five semistructured group sessions (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e) based on the Japanese Psychoeducation Promotion Guidelines toolkit [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]. All five sessions were set up by different experts, and the importance of different interventions was the focus of the lectures. Session 1 was conducted by a psychiatrist, Session 2 by an occupational therapist, Session 3 by a mental health worker, Session 4 by a pharmacist, and Session 5 by a nurse. In addition, two or three nurses attended all the sessions as coleaders.\u003c/p\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eVariables\u003c/h2\u003e\n \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\n \u003ch2\u003eParticipant characteristics\u003c/h2\u003e\n \u003cp\u003eAge, sex, age of onset (first episode), duration (years) of illness, type of hospitalization (involuntary admission or not), duration (days) of hospitalization in the psychiatric acute care ward, chlorpromazine equivalent dose of antipsychotic medication [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e], and Global Assessment of Functioning (GAF) scores [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e] were collected from medical records.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eOutcome\u003c/h2\u003e\n \u003cp\u003eThe primary outcome in this study was the duration of outpatient treatment (DOT) [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]. We defined the day of discharge as day 0 and the day of all-cause discontinuation of outpatient treatment (e.g., readmission, recurrence, suicide, or interruption of regular outpatient hospital visits) as the DOT end day. All participants were followed up for 5 years (1825 days) after discharge via medical records and, if there was difficulty, by phone. In cases where the defining event for DOT could not be determined precisely, we defined the day after the last outpatient visit as censoring and used it for the analysis.\u003c/p\u003e\n \u003cp\u003eThe secondary outcomes were 1) comparative risk (hazard ratio) of all-cause discontinuation of outpatient treatment, 2) the proportion of events precipitating DOT ending each year after discharge, 3) the correlation of DOT with the rates of psychoeducation sessions attended, and 4) changes in QOL dimension scores after the program compared with baseline. We adopted the Japanese version of the Schizophrenia Quality of Life Scale (J-SQLS) as an index of QOL. The J-SQLS is a disease-specific subjective QOL rating scale [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e] used here as an alternative index of the effect of inpatient treatment. This scale consists of three subscales: \u0026ldquo;motivation/energy\u0026rdquo; (ME), \u0026ldquo;psychological/social relations\u0026rdquo; (PS), and \u0026ldquo;symptoms/side effects\u0026rdquo; (SS). The J-SQLS was administered both before and after the psychoeducation program, and raw scores and subscores, as well as changes in scores and subscores after the intervention, were compared within groups and between the CG and NG.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy size calculations\u003c/h2\u003e\n \u003cp\u003eSince no previous studies exist, hazard ratios were assumed, and sample sizes were calculated on the basis of clinical realities. A hazard ratio of 0.3 between the CG and NG, an allocation ratio of 1:1, a study period of 1 year, a follow-up period of 5 years, a log-rank test, 80% statistical power, and a type I error rate of p\u0026thinsp;=\u0026thinsp;0.05 were adopted, and the sample size was calculated to be 14 participants per group, for a total of 28 participants [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. To eliminate the possibility of sampling bias, we attempted to recruit as many participants as possible within the study period.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical analysis\u003c/h2\u003e\n \u003cp\u003eStatistical analyses were performed via SPSS Statistics version 27 (IBM Corp., Armonk, NY, USA). Patient age, age of onset (first episode), duration (years) of illness, duration (days) of hospitalization in the psychiatric acute care ward, GAF score, J-SQLS score, and chlorpromazine equivalent dose in the psychiatric acute care ward were compared between groups by Student\u0026rsquo;s t test or Welch\u0026rsquo;s t test, as indicated, after verifying homoscedasticity. The proportions of sex and type of hospitalization (involuntary admission or not) were compared via Fisher\u0026rsquo;s exact test.\u003c/p\u003e\n \u003cp\u003eDOT was analyzed via the Kaplan\u0026ndash;Meier method and compared between groups via the log-rank test. The hazard ratio for the differential risk of discontinuation of outpatient treatment during follow-up was calculated via the Cox proportional hazard regression model. Cox proportional hazards regression analysis was performed via univariate regression analysis with the following basic variables: age, sex, age of onset, duration of illness, type of admission, chlorpromazine equivalent dose, GAF before the program, J-SQLS subscores (ME, PS, and SS) before the program, completion of the program, and rates of session attended as independent variables. Multivariate analyses were conducted using the independent variables that each showed significant differences (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) in the univariate regression analysis.\u003c/p\u003e\n \u003cp\u003eDisruption event occurrence rates for each year were compared via Fisher\u0026apos;s exact test because fewer than five such events occurred during each year. Correlations between DOT and the number of sessions attended were analyzed via Pearson\u0026rsquo;s method.\u003c/p\u003e\n \u003cp\u003eFor the J-SQLS subscores, independent t tests were used before the program, after the program, and after the program, and between-group comparisons were performed. Paired t tests were used for before/after comparisons and within-group comparisons.\u003c/p\u003e\n \u003cp\u003eAll the statistical comparisons were two-tailed, and the statistical significance level was set at p\u0026thinsp;=\u0026thinsp;0.05. In the case of missing values, those values were excluded, and only the obtained data were analyzed.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eEthical considerations\u003c/h2\u003e\n \u003cp\u003eThis study was conducted with the approval of the Institutional Review Board of Shin-Abuyama Hospital (2016-1) and conformed to the requirements of the latest version of the Declaration of Helsinki. The following ethical considerations were incorporated into the study design, enrollment criteria, follow-up, and analysis: primacy of individual patient wishes, guarantee against therapeutic disadvantages, freedom to withdraw consent, protection of personal data, purpose of use, and disposal of personal data. All participants provided their written consent after receiving a full explanation of the study procedures and patient rights.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eParticipant characteristics\u003c/h2\u003e\n \u003cp\u003eA total of 72 patients with schizophrenia were admitted to the ward during the study period, 61 of whom met the eligibility criteria. Of these, 38 participated in the program, 33 of whom consented to the study. Furthermore, of these 33 participants, one was excluded because of withdrawal of consent. Among the 32 eligible participants, 18 were CGs, and 14 were NGs and were followed for up to 5 years. One CG participant was censored 4 years after discharge (day 1543) because of untraceability after changing doctors due to relocation and changing doctors and phone numbers again, resulting in a final sample of 17 CG and 14 NG participants (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eOf the 32 inpatients enrolled in the study, 18 completed the psychoeducation program (CG), and 14 did not (NG) (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). There were no significant group differences (CG vs. NG) in age, sex ratio, age of onset (first episode), duration (years) of illness, type of hospitalization (involuntary admission or not), duration (days) of hospitalization in the psychiatric acute care ward, chlorpromazine equivalent dose, or GAF score (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Program attendance, DOT and events by participants are summarized in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003c/caption\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003ePrimary outcome (DOT)\u003c/h2\u003e\n \u003cp\u003eThe final analysis included 18 CG and 14 NG participants. Survival analysis revealed significantly longer DOT in the remaining CG patients than in the remaining NG patients (918.2 (174.3) days, 95% CI: 576.7\u0026ndash;1259.8 vs. 225.5 (35.7) days, 95% CI: 155.5\u0026ndash;295.5; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001 by log-rank test) (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eSecondary outcomes\u003c/h2\u003e\n \u003cp\u003eCox proportional hazard regression analysis using univariate analysis with the characteristic variables as independent variables revealed significant differences in age at onset (HR\u0026thinsp;=\u0026thinsp;0.921, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.021), duration (years) of illness (HR\u0026thinsp;=\u0026thinsp;1.070, p\u0026thinsp;=\u0026thinsp;0.003), PS of the J-SQLS subscore (HR\u0026thinsp;=\u0026thinsp;0.975, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.037) and program completion (HR\u0026thinsp;=\u0026thinsp;4.089, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). Multivariate analysis using age of onset, duration (years) of illness, the PS of the J-SQLS subscore, and program completion as independent variables revealed a significant difference in program completion (HR\u0026thinsp;=\u0026thinsp;2.937, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.030). Patients who did not complete the study were at 2.937-fold greater risk of all-cause discontinuation of outpatient treatment than patients who attended all sessions (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eFor all participants, discontinuation of outpatient treatment was attributed to \u0026ldquo;readmission due to recurrence\u0026rdquo; (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). The cumulative number of readmissions was significantly greater among program non-completers than among program completers by the end of each follow-up year (Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eThere was a significantly weak correlation between DOT and the number of sessions attended (Pearson\u0026apos;s \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.384, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.030, 95% CI: 0.001\u0026ndash;0.646) (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eBetween-group comparisons before the program, after the program, and changes in the J-SQLS subscores revealed no significant differences in any of the subscores (CG vs. NG). However, within-group comparisons revealed significant improvements in the \u0026ldquo;psychological/social relations (PS)\u0026rdquo; subscale of the CG and no significant differences in the other subscales (Table \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\n\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo the best of our knowledge, this is the first study comparing the long-term (5 years) efficacy of inpatient psychoeducation for schizophrenia management after hospital release between participants attending all sessions and participants missing one or more (but not all) sessions. Indeed, this is possibly the first pilot cohort study to examine the prognostic impact of the frequency of psychoeducation participation in a small but real-world setting. Therefore, the NG demonstrated an approximately 2.9-fold greater risk of all-cause discontinuation of outpatient treatment as well as earlier readmission for disease relapse. Furthermore, a comparison of subjective QOL at the end of acute psychiatric treatment also revealed a significant improvement in psychological and social QOL among the CG. Thus, program completion improved outcomes in both the short and long term. The results of this study are consistent with those of a previous study in the short term [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Similarly, a recent meta-analysis concluded that complete psychoeducation reduced the recurrence/readmission rate among patients with schizophrenia spectrum disorders in the acute phase [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Furthermore, these interventions had similar preconditions as those of the current study. It is therefore essential that such programs be delivered with sufficient flexibility to allow completion by all inpatients.\u003c/p\u003e \u003cp\u003eRobinson et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] reported that more than half of patients with schizophrenic disorders (63.1%) relapsed within 3 years after the first hospitalization, a rate similar to that of our CG. In contrast, all patients who did not complete the psychoeducation program relapsed within 2 years of discharge. Patients with poor medication adherence as outpatients are 2.4 times more likely to be rehospitalized than those with good medication adherence, and nonadherence is the major cause of relapse or recurrence [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The lower recurrence rate among patients completing our psychoeducation program cannot be explained by the characteristics of the participants in the NG (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e); however, the study suggests that the program may have contributed to improved medication adherence.\u003c/p\u003e \u003cp\u003eThe efficacy of psychoeducation for preventing recurrence has been verified by multiple studies [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In addition, psychoeducation was reported to improve patient QOL [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Similarly, the program described here also improved the \u0026ldquo;PS relations\u0026rdquo; domain of the J-SQLS, suggesting that inpatient treatment, including the program, is more effective than treatment without program completion and potentially provides better preparation for outpatient function.\u003c/p\u003e \u003cp\u003eThere are several distinct models of psychoeducation for patients with schizophrenia, such as programs including the participation of families as well as patients [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], programs delivered exclusively for outpatients or continuing in an outpatient setting [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], and community-based programs [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Programs adopting a combination of educational, behavioral, and emotional strategies are highly effective at maintaining medication adherence and reducing recurrence and readmission [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], whereas psychoeducational interventions without behavioral elements or support services may not be as effective [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In this study, the target, method, frequency, and environment of the intervention differed from those of the aforementioned studies; thus, it is difficult to fully explain the comparison of efficacy rates and the reason for prolonged DOT. Nonetheless, completion of these programs appears essential for full efficacy [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe only clear difference between completers and noncompleters is the amount of knowledge acquired [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], but a causal relationship between the amount of knowledge and recurrence risk has not been demonstrated. Similarly, while poor medication adherence is strongly associated with recurrence [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], no causal relationship has been established between the contents of psychoeducation and adherence. The multiaxial approach to psychoeducation programs by five professions (psychiatrists, occupational therapists, mental health workers, pharmacists and nurses) may have influenced the results of this study and further confirmed a possible correlation between the rates of sessions attended and DOT. These findings strongly support the hypothesis that the completion of psychoeducation programs is essential for relapse prevention and suggest that more program attendance improves outpatient outcomes. In the future, expanding the sample size and further analyzing the relationship between missed content and recurrence may be useful in developing and improving psychoeducation programs.\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eThis study is a pilot study; however, owing to the small sample size, a larger (possibly multicenter) study is warranted. One of the other potential confounders is differences in delivery among leaders of the psychoeducation program. Although our psychoeducation program was created on the basis of a toolkit, there is no nation-wide program in Japan for training psychoeducation practitioners. There are also major differences in program content and emphasis (e.g., number of sessions) among centers. To solve this problem, establishing a standardized program and supervision system to ensure the homogeneity of the program's effectiveness are essential. Next, there are marked differences in cognitive abilities among patients, further compounding heterogeneity in the outcome within and among treatment centers. Although there was no statistically significant difference in the GAF score between the completion and noncompletion groups, it has been reported that disease severity can hinder program completion. More vulnerable patients may not be able to fully learn and use the coping strategies included in the program to prevent recurrence [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Such cases may require more pervasive monitoring rather than relying on the benefits of psychoeducation. It is also critical to identify and validate the most therapeutically effective elements of the program for emphasis, especially for cases with limited cognitive capacity. Finally, we were not able to verify whether the prognosis improved as a result of the completion of psychoeducation and adherence to medication or whether the prognosis improved as a result of improved attitudes toward medication or insight into the disease due to the completion of psychoeducation. To solve this problem, additional studies that include assessments of personality and cognitive function would be appropriate.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eFuture perspective\u003c/h2\u003e \u003cp\u003eIt has been reported that medication adherence may decrease with time following schizophrenia diagnosis [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], whereas the risk of death may increase [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. These findings suggest that interventions aimed at improving adherence should instead be instituted or repeated during this critical period. There is also evidence that psychoeducation is not effective for patients at onset [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Therefore, first hospitalization is an appropriate time for psychoeducation despite challenges in some cases, such as early release or poor patient condition. Future studies should expand the sample size to examine how program completion is related to DOT, along with attitudes toward medication, insight into the disease and medication adherence.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eNoncompletion of an inpatient psychoeducation program resulted in a significantly shorter duration of uninterrupted outpatient treatment and earlier symptom recurrence. These results suggest that the completion of psychoeducation programs has a strong positive effect on patient prognosis. All efforts should be made to allow inpatients the opportunity to complete psychoeducation programs as early as possible after the onset of illness despite time constraints and other challenges to prevent relapse or recurrence.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCG; completion group\u003c/p\u003e\n\u003cp\u003eDOT; duration of outpatient treatment\u003c/p\u003e\n\u003cp\u003eGAF; Global Assessment of Functioning\u003c/p\u003e\n\u003cp\u003eJ-SQLS; Japanese version of the Schizophrenia Quality of Life Scale\u003c/p\u003e\n\u003cp\u003eNG; noncompletion group\u003c/p\u003e\n\u003cp\u003eQOL; quality of life\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted with the approval of the Institutional Review Board of Shin-Abuyama Hospital (2016-1) and conformed to the requirements of the latest version of the Declaration of Helsinki.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll\u0026nbsp;the\u0026nbsp;participants\u0026nbsp;provided\u0026nbsp;written consent after being fully informed of the study procedures and patient rights.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll\u0026nbsp;the\u0026nbsp;participants\u0026nbsp;provided\u0026nbsp;written consent after being fully informed of the study procedures and patient rights.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author\u0026nbsp;upon\u0026nbsp;reasonable request.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHiroki Noguchi, Yoshiki Takei, Koichi Matsumoto, and Hiroshi Yoneda declare no competing interests relevant to\u0026nbsp;the\u0026nbsp;publication of this study. Seiichiro Tarutani has received consulting fees from Janssen Pharmaceutical K.K. and honoraria for lectures from Otsuka Pharmaceutical Co. Ltd., Sumitomo Pharma Co. Ltd., Mochida Pharmaceutical Co. Ltd., Shionogi Pharma Co. Ltd., Viatris Inc., Janssen Pharmaceutical K.K., and Yoshitomiyakuhin Co. Takehiko Okamura has received consulting fees from Otsuka Pharmaceutical Co. Ltd. and honoraria for lectures from Otsuka Pharmaceutical Co. Ltd., Sumitomo Dainippon Pharma Co. Ltd., and Janssen Pharmaceutical K.K.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, H.N. and S.T.; Data curation, H.N. and S.T.; Formal analysis, S.T.; Funding acquisition, S.T.; Investigation, H.N. and S.T.; Methodology, S.T.; Project administration, H.N. and S.T.; Resources, S.T.; Software, S.T.; Supervision, S.T., T.O. and H.Y.; Validation, S.T.; Visualization, H.N., S.T. Y.T. and K.M.; Writing \u0026ndash; original draft, H.N. and S.T.; Writing \u0026ndash; review \u0026amp; editing, S.T. and T.O.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the medical staff of the psychiatric acute care ward (especially Tamami Yamasaki, Kanako Koizumi, Tomoko Kobatake, Kanpei Nakanishi and Ryoichi Ueno) and colleagues in the medical\u0026nbsp;care\u0026nbsp;office at Shin-Abuyama Hospital for their cooperation in this study.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eClinical Trial Registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eXiao J, Mi W, Li L, Shi Y, Zhang H. High relapse rate and poor medication adherence in the Chinese population with schizophrenia: results from an observational survey in the People\u0026apos;s Republic of China. Neuropsychiatr Dis Treat. 2015;11:1161-7. DOI: 10.2147/ndt.S72367\u003c/li\u003e\n\u003cli\u003ePetretto DR, Preti A, Zuddas C, Veltro F, Rocchi MB, Sisti D, et al. Study on psychoeducation enhancing results of adherence in patients with schizophrenia (SPERA-S): study protocol for a randomized controlled trial. Trials. 2013;14:323. DOI: 10.1186/1745-6215-14-323\u003c/li\u003e\n\u003cli\u003eXia J, Merinder LB, Belgamwar MR. Psychoeducation for schizophrenia. Cochrane Database Syst Rev. 2011;2011(6):Cd002831. DOI: 10.1002/14651858.CD002831.pub2\u003c/li\u003e\n\u003cli\u003eLader M. What is relapse in schizophrenia? Int Clin Psychopharmacol. 1995;9 Suppl 5:5-9. DOI: 10.1097/00004850-199501005-00002\u003c/li\u003e\n\u003cli\u003eOlivares JM, Sermon J, Hemels M, Schreiner A. Definitions and drivers of relapse in patients with schizophrenia: a systematic literature review. Ann Gen Psychiatry. 2013;12(1):32. DOI: 10.1186/1744-859x-12-32\u003c/li\u003e\n\u003cli\u003eWorld Health O. ICD-10 : international statistical classification of diseases and related health problems : tenth revision. 2nd ed. Geneva: World Health Organization; 2004.\u003c/li\u003e\n\u003cli\u003eIto J Oshima I, Fukui S. How to start and proceed with psychoeducation based on the guidelines for implementation and dissemination of psychosocial intervention programs. Toolkit-2 (in Japanese). Ichikawa: Community Mental Health \u0026amp; Welfare Bonding Organization; 2009.\u003c/li\u003e\n\u003cli\u003eOshima I, Fukui S. How to start and proceed with psychoeducation based on the guidelines for implementation and dissemination of psychosocial intervention programs. Toolkit-1 (in Japanese). Ichikawa: Community Mental Health \u0026amp; Welfare Bonding Organization; 2011.\u003c/li\u003e\n\u003cli\u003eInada T, Inagaki A. Psychotropic dose equivalence in Japan. Psychiatry Clin Neurosci. 2015;69(8):440-7. DOI: 10.1111/pcn.12275\u003c/li\u003e\n\u003cli\u003eHall RC. Global assessment of functioning. A modified scale. Psychosomatics. 1995;36(3):267-75. DOI: 10.1016/s0033-3182(95)71666-8\u003c/li\u003e\n\u003cli\u003eJones SH, Thornicroft G, Coffey M, Dunn G. A brief mental health outcome scale-reliability and validity of the Global Assessment of Functioning (GAF). Br J Psychiatry. 1995;166(5):654-9. DOI: 10.1192/bjp.166.5.654\u003c/li\u003e\n\u003cli\u003eTarutani S, Kikuyama H, Ohta M, Kanazawa T, Okamura T, Yoneda H. Association between Medication Adherence and Duration of Outpatient Treatment in Patients with Schizophrenia. Psychiatry Investig. 2016;13(4):413-9. DOI: 10.4306/pi.2016.13.4.413\u003c/li\u003e\n\u003cli\u003eKaneda Y, Imakura A, Fujii A, Ohmori T. Schizophrenia Quality of Life Scale: validation of the Japanese version. Psychiatry Res. 2002;113(1-2):107-13. DOI: 10.1016/s0165-1781(02)00240-8\u003c/li\u003e\n\u003cli\u003eKarow A, Naber D. Subjective well-being and quality of life under atypical antipsychotic treatment. Psychopharmacology (Berl). 2002;162(1):3-10. DOI: 10.1007/s00213-002-1052-z\u003c/li\u003e\n\u003cli\u003eLakatos E. Sample sizes based on the log-rank statistic in complex clinical trials. Biometrics. 1988;44(1):229-41. PMID: 3358991\u003c/li\u003e\n\u003cli\u003eLakatos E, Lan KK. A comparison of sample size methods for the logrank statistic. Stat Med. 1992;11(2):179-91. DOI: 10.1002/sim.4780110205\u003c/li\u003e\n\u003cli\u003eChabannes JP, Bazin N, Leguay D, Nuss P, Peretti CS, Tatu P, et al. Two-year study of relapse prevention by a new education program in schizophrenic patients treated with the same antipsychotic drug. Eur Psychiatry. 2008;23(1):8-13. DOI: 10.1016/j.eurpsy.2007.09.003\u003c/li\u003e\n\u003cli\u003eBarnicot K, Michael C, Trione E, Lang S, Saunders T, Sharp M, et al. Psychological interventions for acute psychiatric inpatients with schizophrenia-spectrum disorders: A systematic review and meta-analysis. Clin Psychol Rev. 2020;82:101929. DOI: 10.1016/j.cpr.2020.101929\u003c/li\u003e\n\u003cli\u003eRobinson D, Woerner MG, Alvir JM, Bilder R, Goldman R, Geisler S, et al. Predictors of relapse following response from a first episode of schizophrenia or schizoaffective disorder. Arch Gen Psychiatry. 1999;56(3):241-7. DOI: 10.1001/archpsyc.56.3.241\u003c/li\u003e\n\u003cli\u003eCaseiro O, P\u0026eacute;rez-Iglesias R, Mata I, Mart\u0026iacute;nez-Garcia O, Pelayo-Ter\u0026aacute;n JM, Tabares-Seisdedos R, et al. Predicting relapse after a first episode of nonaffective psychosis: a three-year follow-up study. J Psychiatr Res. 2012;46(8):1099-105. DOI: 10.1016/j.jpsychires.2012.05.001\u003c/li\u003e\n\u003cli\u003eValenstein M, Copeland LA, Blow FC, McCarthy JF, Zeber JE, Gillon L, et al. Pharmacy data identify poorly adherent patients with schizophrenia at increased risk for admission. Med Care. 2002;40(8):630-9. DOI: 10.1097/00005650-200208000-00002\u003c/li\u003e\n\u003cli\u003eHerz MI, Lamberti JS, Mintz J, Scott R, O\u0026apos;Dell SP, McCartan L, et al. A program for relapse prevention in schizophrenia: a controlled study. Arch Gen Psychiatry. 2000;57(3):277-83. DOI: 10.1001/archpsyc.57.3.277\u003c/li\u003e\n\u003cli\u003eAtkinson JM, Coia DA, Gilmour WH, Harper JP. The impact of education groups for people with schizophrenia on social functioning and quality of life. Br J Psychiatry. 1996;168(2):199-204. DOI: 10.1192/bjp.168.2.199\u003c/li\u003e\n\u003cli\u003eAguglia E, Pascolo-Fabrici E, Bertossi F, Bassi M. Psychoeducational intervention and prevention of relapse among schizophrenic disorders in the Italian community psychiatric network. Clin Pract Epidemiol Ment Health. 2007;3:7. DOI: 10.1186/1745-0179-3-7\u003c/li\u003e\n\u003cli\u003eHornung WP, Feldmann R, Klingberg S, Buchkremer G, Reker T. Long-term effects of a psychoeducational psychotherapeutic intervention for schizophrenic outpatients and their key-persons--results of a five-year follow-up. Eur Arch Psychiatry Clin Neurosci. 1999;249(3):162-7. DOI: 10.1007/s004060050082\u003c/li\u003e\n\u003cli\u003eDolder CR, Lacro JP, Leckband S, Jeste DV. Interventions to improve antipsychotic medication adherence: review of recent literature. J Clin Psychopharmacol. 2003;23(4):389-99. DOI: 10.1097/01.jcp.0000085413.08426.41\u003c/li\u003e\n\u003cli\u003ePhan SV. Medication adherence in patients with schizophrenia. Int J Psychiatry Med. 2016;51(2):211-9. DOI: 10.1177/0091217416636601\u003c/li\u003e\n\u003cli\u003eZygmunt A, Olfson M, Boyer CA, Mechanic D. Interventions to improve medication adherence in schizophrenia. Am J Psychiatry. 2002;159(10):1653-64. DOI: 10.1176/appi.ajp.159.10.1653\u003c/li\u003e\n\u003cli\u003eMacpherson R, Jerrom B, Hughes A. A controlled study of education about drug treatment in schizophrenia. Br J Psychiatry. 1996;168(6):709-17. DOI: 10.1192/bjp.168.6.709\u003c/li\u003e\n\u003cli\u003eEmsley R, Chiliza B, Asmal L, Harvey BH. The nature of relapse in schizophrenia. BMC Psychiatry. 2013;13:50. DOI: 10.1186/1471-244x-13-50\u003c/li\u003e\n\u003cli\u003eKlingberg S, Buchkremer G, Holle R, Schulze M\u0026ouml;nking H, Hornung WP. Differential therapy effects of psychoeducational psychotherapy for schizophrenic patients--results of a 2-year follow-up. Eur Arch Psychiatry Clin Neurosci. 1999;249(2):66-72. DOI: 10.1007/s004060050068\u003c/li\u003e\n\u003cli\u003eTiihonen J, L\u0026ouml;nnqvist J, Wahlbeck K, Klaukka T, Niskanen L, Tanskanen A, et al. 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study). Lancet. 2009;374(9690):620-7. DOI: 10.1016/s0140-6736(09)60742-x\u003c/li\u003e\n\u003cli\u003eFeldmann R, Hornung WP, Prein B, Buchkremer G, Arolt V. Timing of psychoeducational psychotherapeutic interventions in schizophrenic patients. Eur Arch Psychiatry Clin Neurosci. 2002;252(3):115-9. DOI: 10.1007/s00406-002-0369-2\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"schizophrenia, psychoeducation, completion, duration of outpatient treatment (DOT)","lastPublishedDoi":"10.21203/rs.3.rs-4868072/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4868072/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePsychoeducation programs can reduce the risk of recurrence and readmission in patients with schizophrenia. However, almost all previous studies of program efficacy have included only patients completing the program, which may not be possible in all cases. The objective of this pilot cohort study was to compare the prognoses of inpatients with schizophrenia who did or did not complete a well-established institutional psychoeducation program.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study is a pilot cohort study, and the participants were 32 inpatients in the psychiatric acute care ward. Among these patients, 18 completed the institutional psychoeducation program by discharge, whereas 14 missed one or more sessions for various reasons. The primary outcome was the duration of outpatient treatment (DOT) during the 5-year follow-up period, and the secondary outcomes were comparisons of the risk of all-cause discontinuation for outpatient treatment and correlations between the program participation rate and DOT.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eDOT was significantly longer in the program completion group than in the noncompletion group (918.2 (174.3) days vs. 225.5 (35.7) days, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001), and Cox proportional hazards regression analysis revealed that program noncompliance was associated with a 4.089-fold (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002) greater risk of discontinuation of outpatient treatment according to univariate analysis and a 2.937-fold (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.030) greater risk according to multivariate analysis. A significant weak correlation was found for DOT and rates of sessions admitted to the programme (Pearson's \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.384, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.030).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eCompletion of a psychoeducation program dramatically enhanced the success of outpatient treatment. Because of the significant impact of outpatient treatment on prognosis, inpatient psychoeducation programs should be sufficiently flexible to provide opportunities for completion.\u003c/p\u003e","manuscriptTitle":"Prognostic impact of psychoeducation program completion on inpatients with schizophrenia: a pilot cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-11 15:18:25","doi":"10.21203/rs.3.rs-4868072/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-04T17:19:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-28T04:07:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-20T15:36:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-08T20:56:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"90513470512081848523303195119129127865","date":"2024-09-22T15:43:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"267609851667201123666352275582595684832","date":"2024-09-22T14:41:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"217103176686770872713811825146483079205","date":"2024-09-22T14:20:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"168740431335994982447829733214739374909","date":"2024-09-21T20:57:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-27T08:55:38+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-08-07T14:30:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-07T02:25:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-07T02:24:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2024-08-06T11:20:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"19229baf-ab3c-416f-83f9-bff433d4c685","owner":[],"postedDate":"September 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-20T16:05:18+00:00","versionOfRecord":{"articleIdentity":"rs-4868072","link":"https://doi.org/10.1186/s12888-024-06397-5","journal":{"identity":"bmc-psychiatry","isVorOnly":false,"title":"BMC Psychiatry"},"publishedOn":"2025-01-17 15:57:11","publishedOnDateReadable":"January 17th, 2025"},"versionCreatedAt":"2024-09-11 15:18:25","video":"","vorDoi":"10.1186/s12888-024-06397-5","vorDoiUrl":"https://doi.org/10.1186/s12888-024-06397-5","workflowStages":[]},"version":"v1","identity":"rs-4868072","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4868072","identity":"rs-4868072","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}