The Effectiveness of Art Therapy in the Rehabilitation of Patients With Schizophrenia

• Periodical List
• Front Psychol
• PMC4858645

Front end Psychol. 2016; 7: 631.

Brute Assisted Therapy (AAT) Program Every bit a Useful Adjunct to Conventional Psychosocial Rehabilitation for Patients with Schizophrenia: Results of a Pocket-size Randomized Controlled Trial

Paula Calvo,^{ane, two, *} Joan R. Fortuny,³ Sergio Guzmán,³ Cristina Macías,^three Jonathan Bowen,^{i, 4} María L. García,³ Olivia Orejas,³ Ferran Molins,^three Asta Tvarijonaviciute,^{5, six} José J. Cerón,⁵ Antoni Bulbena,^{1, 2, iii} and Jaume Fatjó^{1, 2}

Paula Calvo

^oneChair Affinity Foundation Animals and Health, Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain

²Hospital del Mar Medical Research Constitute, Barcelona, Kingdom of spain

Joan R. Fortuny

³Centres Assistencials Emili Mira, Institut de Neuropsiquiatria i Addiccions, Parc de Salut Mar, Santa Coloma de Gramenet, Spain

Sergio Guzmán

³Centres Assistencials Emili Mira, Institut de Neuropsiquiatria i Addiccions, Parc de Salut Mar, Santa Coloma de Gramenet, Kingdom of spain

Cristina Macías

³Centres Assistencials Emili Mira, Institut de Neuropsiquiatria i Addiccions, Parc de Salut Mar, Santa Coloma de Gramenet, Spain

Jonathan Bowen

¹Chair Affinity Foundation Animals and Wellness, Section of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain

^ivQueen Female parent Hospital for Small Animals, The Majestic Veterinary Higher, Hertfordshire, Uk

María L. García

³Centres Assistencials Emili Mira, Institut de Neuropsiquiatria i Addiccions, Parc de Salut Mar, Santa Coloma de Gramenet, Spain

Olivia Orejas

³Centres Assistencials Emili Mira, Institut de Neuropsiquiatria i Addiccions, Parc de Salut Mar, Santa Coloma de Gramenet, Spain

Ferran Molins

³Centres Assistencials Emili Mira, Institut de Neuropsiquiatria i Addiccions, Parc de Salut Mar, Santa Coloma de Gramenet, Spain

Asta Tvarijonaviciute

⁵Interlab-UMU, Campus de Excelencia Mare Nostrum, Universidad de Murcia, Murcia, Espana

⁶Department of Medicine and Animal Surgery, Universitat Autònoma de Barcelona, Bellaterra, Kingdom of spain

José J. Cerón

^fiveInterlab-UMU, Campus de Excelencia Mare Nostrum, Universidad de Murcia, Murcia, Spain

Antoni Bulbena

¹Chair Affinity Foundation Animals and Health, Section of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Bellaterra, Espana

²Infirmary del Mar Medical Research Institute, Barcelona, Kingdom of spain

³Centres Assistencials Emili Mira, Institut de Neuropsiquiatria i Addiccions, Parc de Salut Mar, Santa Coloma de Gramenet, Kingdom of spain

Jaume Fatjó

ⁱChair Affinity Foundation Animals and Health, Section of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain

^twoHospital del Mar Medical Inquiry Establish, Barcelona, Spain

Received 2015 Dec 31; Accustomed 2016 Apr 15.

Abstruse

Currently, one of the master objectives of human–animal interaction research is to demonstrate the benefits of creature assisted therapy (AAT) for specific profiles of patients or participants. The aim of this study is to assess the effect of an AAT program every bit an adjunct to a conventional vi–month psychosocial rehabilitation programme for people with schizophrenia. Our hypothesis is that the inclusion of AAT into psychosocial rehabilitation would contribute positively to the impact of the overall program on symptomology and quality of life, and that AAT would be a positive experience for patients. To test these hypotheses, we compared pre–program with mail service–program scores for the Positive and Negative Syndrome Scale (PANSS) and the EuroQoL-5 dimensions questionnaire (EuroQol-5D), pre–session with postal service–session salivary cortisol and alpha–amylase for the last four AAT sessions, and adherence rates between different elements of the programme. We conducted a randomized, controlled written report in a psychiatric intendance heart in Espana. Twenty–ii institutionalized patients with chronic schizophrenia completed the 6–month rehabilitation plan, which included private psychotherapy, group therapy, a functional program (intended to improve daily functioning), a customs program (intended to facilitate community reintegration) and a family unit program. Each member of the control grouping (n = 8) participated in ane activity from a range of therapeutic activities that were office of the functional plan. In place of this functional program action, the AAT–treatment group (n = 14) participated in twice–weekly 1–h sessions of AAT. All participants received the same weekly total number of hours of rehabilitation. At the stop of the programme, both groups (control and AAT–treatment) showed significant improvements in positive and overall symptomatology, as measured with PANSS, simply but the AAT–treatment group showed a significant improvement in negative symptomatology. Adherence to the AAT-treatment was significantly college than overall adherence to the control grouping's functional rehabilitation activities. Cortisol level was significantly reduced afterward participating in an AAT session, which could indicate that interaction with the therapy dogs reduced stress. In determination, the results of this modest RCT suggest that AAT could be considered a useful adjunct to conventional psychosocial rehabilitation for people with schizophrenia.

Keywords: beast-assisted therapy, psychosocial rehabilitation, adherence to handling, schizophrenia, PANSS, EuroQol-v dimensions, salivary cortisol, salivary blastoff-amylase

Introduction

Interactions with companion animals appear to accept positive furnishings on physiological, psychological, and social aspects of homo wellbeing (Fine, 2010). Brute assisted therapies (AAT) seem to produce therapeutic benefits in unlike kinds of patients, from those with concrete ailments, such as cardiovascular disease, to those with mental disorders ranging from dementia to low (Pedersen et al., 2011) and schizophrenia (Barak et al., 2001). It has been suggested that AAT might help to develop the therapeutic relationship between patients and healthcare professionals, and could improve the therapeutic atmosphere (Fine, 2010; Julius et al., 2013); animals in AAT can human action as social facilitators, social modulators, and amplifiers of emotional reactivity (Fine, 2010).

However, scientific evidence for the benefits of AAT is notwithstanding very limited (Nimer and Lundahl, 2007; Kamioka et al., 2014), partially due to intrinsic difficulties of performing research with AAT (Nimer and Lundahl, 2007; Kamioka et al., 2014). Typical methodological limitations of AAT include: pocket-size sample size, difficulties of blinding, lack of an adequate control group, pick bias due to including simply participants who like animals, lack of physiological evaluation, short program duration and the limited number of professionals and animals that currently participate in AAT. Some of these limitations are very difficult to overcome, because of the nature of AAT interventions. For case, in AAT, it is very difficult to find a comparable therapeutic activity for the control group, and it is impossible to blind for the presence of the creature. Since AAT is nonetheless considered an alternative therapeutic approach, very few resources are dedicated to it inside the health organization (Kaplan and Sadock, 1989). Every bit a consequence of these limitations it is important to compile studies with fractional bear witness for AAT efficacy and applicability (Fine, 2010) and to meliorate and standardize enquiry methodologies (Kamioka et al., 2014).

Recent reviews of AAT research betoken that mental health disorders are a expert target for AAT interventions (Nimer and Lundahl, 2007; Villalta-Gil and Ochoa, 2007; Rossetti and Rex, 2010; Kamioka et al., 2014). Some studies have shown that AAT programs could benefit patients being treated for schizophrenia (Kovács et al., 2004, 2006; Nathans-Barel et al., 2005; Chu et al., 2009). Suggested benefits include effects on self-esteem, self-determination, positive symptomatology, emotional symptomatology, anhedonia, and daily performance (Nathans-Barel et al., 2005; Villalta-Gil and Ochoa, 2007; Villalta-Gil et al., 2009; Kamioka et al., 2014).

The aim of this report was to assess the effect of an AAT program as an adjunct to conventional psychosocial rehabilitation for people with schizophrenia.

Based on the hypothesis that inclusion of AAT in a rehabilitation programme would have a benign effect, our report had three objectives; to analyze the impact on symptomatology and quality of life, to evaluate the patient's experience of the AAT sessions, and to appraise stress relief during the AAT sessions. For the offset objective, the measures used were the Positive and Negative Syndrome Calibration (PANSS; Kay et al., 1989; Peralta and Cuesta, 1994), and EuroQoL-five Dimensions questionnaire (EQ-5D; Bobes et al., 2005). For the second objective, we used adherence (proportion of programmed sessions that a patient attended). Adherence was used every bit an indicator of the relative appeal of the AAT sessions, by comparing adherence for the AAT sessions with combined adherence for the functional program attended by the command grouping. For the last objective, since stress management is one of the main objectives for the handling of inpatients with mental disorders (Klainin-Yobas et al., 2015), we evaluated the stress-relieving aspect of the sessions past making a pre- versus post-session comparing of values for salivary cortisol and alpha-amylase for the last four AAT sessions. To our noesis, previous research on the effects of AAT for patients with schizophrenia has not included the combination of these 3 different types of objectives (and the associated measures).

Our general objective was to present evidence that was dissimilar and complementary to existing inquiry and to place interesting target measures, such as adherence to treatment and physiological measures, that could be used for future research.

Materials and Methods

Study Pattern

The study was a randomized, controlled trial (RCT).

In this written report, primary outcomes for all participants were changes in symptomatology (measured with PANSS) and changes in quality of life (measured with EQ-5D). Secondary outcomes of this study consisted of adherence to AAT sessions (AAT-treatment grouping) versus adherence to other activities of functional rehabilitation (control group), and changes in salivary cortisol and alpha-amylase during AAT sessions, equally a mensurate of stress relief (AAT-treatment group only).

Patients were randomly assigned to the control or AAT-treatment group.

The laboratory technicians who analyzed the saliva samples were simply given the patients' ID numbers, and were blinded to whether patients were in the control or AAT-treatment group. For applied reasons and for bug relating to the availability of resources and personnel, the rest of the process of the study could not be blinded. Information technology was not possible for patients to be blinded to the presence of dogs, and only one hospital neuropsychologist was able to participate in the study (in charge of all of the pre-treatment and mail service-handling evaluations of the report, and follow-up of all of the patients). A single researcher non only carried out the drove of the information and saliva samples, but as well acted equally a guide for the therapy dogs during the AAT sessions.

Sample

The study was conducted in a public psychiatric infirmary within an urban area of Spain. In order to avoid the confounding furnishings of environmental variation, only patients from the same unit were included (MILLE: Long and medium-stay unit of measurement). All eligible patients from the MILLE unit who fulfilled the post-obit criteria were included:

• • Diagnosis of schizophrenia, according to the Revised forth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-Iv-TR; American Psychiatric Association, 2000).
• • Enrolled in a psychosocial rehabilitation process.
• • With a projected minimum hospitalization term of six months.

A set of exclusion criteria was besides applied, which included:

• • Compromised mobility.
• • Presence of allergies to animals.
• • Rejection of contact with companion animals.
• • Confirmed diagnosis of a coagulopathy.

These inclusion and exclusion criteria were adjusted from previous AAT protocols (Barak et al., 2001; Kovács et al., 2004; Nathans-Barel et al., 2005; Villalta-Gil et al., 2009; Fine, 2010; Lang et al., 2010). All patients in the unit of measurement who met the criteria were included in the study.

Twenty-four adult patients (Hateful age = 47.8 years of historic period; SD = vi.vii) fulfilled the requirements and were included in the study. The patients' hateful age at diagnosis of schizophrenia was 20.v years of historic period (SD = v.0). The patients' mean scores for PANSS were: 43.eight (SD = 12.3) for General PANSS, 24 (SD = half dozen.six) for Negative PANSS and 20.6 (SD = 6.six) for Positive PANSS. The EQ-5D total score mean was 1.eight (SD = 1.5). See Table ​ 1 for an overview of all of the characteristics of the sample population.

Table 1

Characteristics of the sample.

Patient	Group	Age	Age of onset	Gender	PANSS General	PANSS Negative	PANSS Positive	EQ-5D full	Psychotropic medication	Other medication
one	T	54	17	Homo	31	25	11	0	Aripripazol, levomepromazine	Pravastatin, repaglinide, pantoprazole
two	T	66	xx	Woman	38	18	22	3	Clozapine, venlafaxine	Pantoprazole, lactulose
iii	T	37	21	Man	32	17	nine	one	Clozapine, amisulpride, lorazepam, pregabalin	–
iv	T	58	22	Man	46	36	24	two	Fluphenazine, levomepromazine, biperiden	–
5	T	52	26	Man	50	32	23	i	Clozapine, sodium valproate	Metformin
half-dozen	T	47	twenty	Human	38	nineteen	13	one	Zuclopenthixol, biperiden	Atorvastatin
vii	T	41	15	Human being	77	39	28	iii	Levomepromazine, periciazine, paroxetine, biperiden	–
8	T	33	23	Adult female	31	12	15	0	Zuclopenthixol, clonazepam, sodium valproate, biperiden	Gemfibrozil
9	T	35	24	Man	46	25	18	ii	Clozapine, fluphenazine, pimozide, clotiapine	–
ten	T	47	21	Man	53	29	25	one	Fluphenazine, risperidone, biperiden	Lactulose
xi	T	54	15	Adult female	37	29	17	1	Risperidone, zuclopenthixol, sodium valproate	–
12	T	44	22	Woman	37	22	27	3	Clozapine, risperidone	Atorvastatin, salmeterol
13	T	fifty	17	Man	43	24	17	7	Lithium carbonate, clozapine, methylphenidate, sertraline, topiramate, biperiden	Monohydrate lactitol
14	T	55	39	Man	61	27	15	two	Olanzapine, paroxetine, dipotassium cloracepate, biperiden	Hydroxyzine, loratadine
xv	T	43	21	Man	47	30	30	2	Fluphenazine, risperidone, sodium valproate	–
16	T	45	nineteen	Man	42	18	34	2	Clozapine, diazepam, sodium valproate	Pantoprazole, lactulose, gemfibrozil
17	C	48	18	Woman	45	26	xviii	four	Clozapine	–
eighteen	C	47	xvi	Man	fifty	20	14	i	Haloperidol, dipotassium clorazepate, biperiden	Lactulose
xix	C	53	21	Human being	46	16	25	two	Risperidone, quetiapine, sodium valproate, clonazepam	Atenolol, pravastatin, pantoprazole, metformin
20	C	59	25	Man	44	22	21	2	Clozapine, gabapentin, biperiden	–
21	C	51	xvi	Man	61	26	28	0	Zuclopenthixol, ziprasidone, sodium valproate, biperiden	–
22	C	50	twenty	Man	xv	22	12	0	clozapine	Enalapril
23	C	44	18	Woman	48	xv	22	ii	Zuclopenthixol, levomepromazine, clotiapine	–
24	C	50	sixteen	Adult female	32	27	26	1	Olanzapine, levomepromazine, sodium valproate, phenytoin	–
Hateful (SD)	–	47.viii (half-dozen.7)	20.5 (five.0)	–	43.7 (12.3)	20.6 (half-dozen.6)	24 (vi.six)	one.8 (1.v)	–	–

The 24 patients who met the inclusion criteria were randomly assigned to 3 groups, with eight patients in each group (AAT-treatment groups A and B, and a command grouping C) (See Figure ​ one ). Given the length of the study (six months), a loftier drop out rate was expected. Other authors recommend that group size is kept small for AAT sessions (Kovács et al., 2004; Nathans-Barel et al., 2005; Chu et al., 2009; Fine, 2010). To comply with this recommendation, the 16 patients who were to exist given AAT were randomly allocated to i of two small therapy groups (eight people in each). There were no differences in the characteristics of these groups, or in the AAT-therapy they received. In the analysis, data from patients in both therapy groups (A and B) was therefore combined into a unmarried group.

Shows the modified CONSORT flow diagram for private RCTs of non-pharmacologic handling (Boutron et al., 2008; Schulz et al., 2010) applied to this study.

V therapy dogs that had previously been assessed and trained, and had experience of participation in AAT work were used for the study. There is no official dog therapy certification in Espana. A thorough physical and behavioral test of each canis familiaris was performed by a console of three board-certified specialists in veterinary behavioral medicine. This examination included the Ethotest (Lucidi et al., 2005), a test designed to identify suitable therapy dogs, and the C-BARQ (Hsu and Serpell, 2003), a questionnaire for measuring behavior and temperament traits in dogs.

Interventions

The report took place between Oct 2012 and May 2013. At the psychiatric hospital where the written report was conducted, the global psychosocial rehabilitation process consisted of five types of programs: private psychotherapy, group therapy programme, functional program (to amend daily functioning), community program (with social reintegration objectives), and family program. From Monday to Fri every calendar week, all patients treated in this global psychosocial rehabilitation procedure had to participate in all five types of program.

Patients in all groups participated in the same full weekly number of hours of activity within the psychosocial rehabilitation procedure. For the AAT-therapy groups (A and B) the AAT program was one of these activities. The AAT plan consisted of half dozen-months of twice-weekly 1-h sessions (Tuesday and Fri), so that each patient attended a full of forty AAT sessions (taking into account public holidays). Control grouping patients attended the same number of sessions in the functional program.

The AAT-treatment involved 3 types of sessions:

• (a)

  Sessions to develop the emotional bond between participants and dogs: The participants were taught to handle and take intendance of the dogs correctly. In this type of session, concepts of animal welfare and responsible buying were explained and good.

• (b)

  Sessions involving walking the dogs: During the first half of the plan, the dogs were walked in a large natural park, so that the patients could learn to walk the dogs in a calm and controlled manner. For the rest of the program, the participants walked the dogs in the city, where they could feel canis familiaris-walking in a social context that is typical of that which is experienced by domestic dog owners.

• (c)

  Sessions to railroad train and play with dogs: Patients learned to give instructions to the dogs and train them using positive reinforcement training techniques.

During an AAT session four of the 5 therapy dogs were always present to collaborate with the patients. At the beginning of each session, participants were asked to work in pairs. Each working pair was assigned a domestic dog, which they worked with for the remaining hour of the session. During the program there was a rotation between the three types of sessions (emotional bonding, domestic dog walking, and dog training with play).

Each patient in the control group was assigned to a single action from the functional program on the basis of their therapist's criteria, but taking into business relationship the private's preferences. The choice was between art therapy, group sports (football or basketball game), dynamic psycho-stimulation, and gymnastics. These activities were organized and so that they closely matched sure important characteristics of the AAT program:

• • They were conducted outside the hospital unit where the patients were resident.
• • They all involved a similar element of group work.
• • Group sizes were modest (like to the AAT sessions).
• • Patients were accompanied and supervised off-site by a mental health professional person (nurse or similar).
• • The activities continued throughout the period of trial (they were unaffected by season).
• • The sessions were twice-weekly and of one-h duration.

The difference between functional programme activities and the AAT sessions was, equally far as was possible, restricted to content.

Instruments

To compare development in psychiatric symptoms between AAT-treatment and control patients during the six-month duration of the programme, we used the previously validated Spanish version of the Positive and Negative Syndrome Scale (PANSS; Kay et al., 1989). PANSS has been plant to be a reasonably valid psychometric tool for people with schizophrenia (Kay et al., 1989; Peralta and Cuesta, 1994), and is 1 of the most widely used tools for the cess of therapeutic results in schizophrenia treatment. PANSS was administered to all patients during individualized interviews with the infirmary neuropsychologist. Information technology was completed for each patient several times in the month before the study started, during the program and in the calendar month afterwards the end of the program.

The same interview approach was used to assess quality of life, using the EQ-5D (Bobes et al., 2005). The EQ-5D has been found to be reasonably valid for use in people with schizophrenia (König et al., 2007) and is a standard cess musical instrument used in this infirmary. The neuropsychologist completed the EQ-5D twice with each patient, in the month earlier the written report started and in the month afterward the end of the program.

Individual omnipresence at sessions of AAT and the functional program was recorded. Adherence was calculated every bit the proportion of programmed sessions that a patient attended during the 6-month plan period, expressed as a percentage.

In social club to study the physiological effects of contact with the dogs during an AAT session, pre- and mail-session saliva samples were nerveless for the last iv AAT sessions of the programme. Salivary alpha-amylase (sAA) and cortisol were measured. Equally a biomarker of psychosocial stress, salivary alpha-amylase tin be considered to be a mensurate of the level of activation of the sympathetic nervous system (SNS; Rohleder et al., 2006; Holt-Lunstad et al., 2008). Salivary cortisol is an indicator of the state of the hypothalamic–pituitary–adrenal (HPA) centrality and is a general physiological biomarker of stress (Fortunato et al., 2008; Holt-Lunstad et al., 2008). Saliva samples were collected using a commercial saliva drove kit (Salivettes^®, Sarstedt), with the Salivette remaining in the patient'southward mouth for i min per sample. Two samples were collected from each patient at each of the iv sessions; 1 was collected 30 min before the AAT session and the other 10 min after the AAT session had finished. Saliva samples were stored in a dry out-water ice cooled mobile fridge, in which they were delivered to the laboratory to be processed and frozen to −80°C for after testing. The maximum pre-freezing storage time was iv h. After the study was completed, all saliva samples were thawed and analyzed. Cortisol was extracted and analyzed using a commercial immunoassay (Siemens IMMULITE 2000, Siemens Healthcare Diagnostics. Deerfield, IL, U.s.a.; Owen and Roberts, 2011; Tecles et al., 2014), and blastoff-amylase was analyzed using a commercial spectrophotometric assay (Olympus AU2700. Olympus America Inc. Center Valley, PA, USA; Tecles et al., 2014).

Statistical Analysis

We analyzed data from all the participants who completed the 6-month period of the study (N = 22). In the present study, patients were included in the analysis regardless of their level of adherence to their medication authorities or any of the five elements of the psychosocial rehabilitation procedure, and adherence to the AAT program was a main consequence measure. As a result, the present written report does not comply with the requirements for a 'per protocol' assay, in which patients would be excluded for any deviation from treatment. However, because we excluded ii patients who did not complete the report we likewise did not carry out an 'intention to care for' assay, and so our protocol could be described as a 'modified intention to treat.'

Betwixt-group (control and AAT-handling) contrasts of PANSS and EQ-5D scores were analyzed using Statistica 10 and GraphPad Prism half dozen. Data was tested for normality using the Shapiro–Wilk test; parametric data was tested using a t-test, and non-parametric data was tested using the Mann–Whitney U (for unpaired data) or Wilcoxon exam (for paired data). For dichotomous variables (patient sex), a chi-square examination was used to compare proportions between groups. Multiple comparisons were made in the EQ-5D analysis, so the Bonferroni correction was used to adjust the value of p that was accustomed for significance (for example, for 20 comparisons, p = 0.05/20 = 0.0025).

Pre-program PANSS and EQ-5D scores were compared with post-program scores, for the AAT-treatment and command groups separately. After checking normality of data (with the Shapiro–Wilk test), a paired-samples t-test was used with parametric data and the Wilcoxon exam was used with non-parametric data.

Adherence to treatment data was checked for normality using the Shapiro–Wilk examination. An unpaired t-test (for parametric data) or Isle of mann–Whitney U (for non-parametric data) was used to compare adherence levels between the AAT-handling grouping and either overall compliance or compliance for individual activities inside the functional programs (control group).

A paired t-examination was used to compare pre- with post-session levels of cortisol and blastoff-amylase in the AAT-treatment group (data had been found to exist usually distributed using the Shapiro–Wilk test).

Ethics

The Clinical Research Ethics Committee of the Hospital del Mar Medical Research Plant (IMIM) approved the clinical-protocol, patient management, and participation of the patients.

The Department of Agriculture and Natural Environment of the Catalonia Regime approved the animal management protocol for this study. All dogs that participated in the projection were given a thorough medical, behavioral, and welfare assessment before, during, and after the AAT program.

All patients who were eligible for the study received documentation that outlined the written report, and they signed an informed consent form. They were able to withdraw from the study at whatsoever time.

Animal assisted therapy technicians signed an informed consent form that detailed their responsibilities (confidentiality and conformity) within the project.

Spanish law 15/99 (regarding personal information protection) was applied to all data collection.

Results

Sample Characteristics

There were no differences between control and AAT-treatment groups with respect to sex [Chi-square test; χ²(1) = 0.xl], age or initial scores of PANSS and EQ-5D (Mann–Whitney U; p < 0.05; Meet Table ​ 2 for full details).

Table 2

Initial scores of PANSS and EQ-5D of the analyzed patients of this study.

	Hateful (SD)
INITIAL SCORES	Treatment (North = fourteen)	Command (N = 8)	U	Z adjusted	two sided verbal p ∗
AGE	48.9 (6.7)	46.7 (7.iii)	40.5	1.02	0.29
PANSS positive	18.9 (6.0)	20.vii (5.seven)	46	−0.64	0.52
PANSS negative	25.3 (seven.5)	21.lxx (4.v)	39.five	i.09	0.26
PANSS general	44.3 (12.3)	42.6 (13.seven)	51.5	−0.27	0.76
EQ-5D Total score	one.nine (ane.eight)	1.5 (1.iii)	49.5	0.42	0.66
EQ-5D- Health Today (0–100)	eighty.7 (24.9)	78.7 (eighteen.iii)	42	0.94	0.36
EQ-5D- F1 Mobility	0.ane (0.3)	0.1 (0.iii)	53	−0.34	0.86
EQ-5D- F2 Personal Care	0.ane (0.4)	∗∗	48	1.02	0.61
EQ-5D- F3 Daily Activities	0.ane (0.3)	0.2 (0.7)	52.5	−0.41	0.81
EQ-5D- F4 Pain/Discomfort	0.4 (0.6)	0.five (0.five)	50	-0.43	0.71
EQ-5D- F6 Health Land 12 m	0.iv (0.half dozen)	0.four (0.seven)	51.v	0.33	0.76

During the programme, two patients within the AAT-treatment group withdrew from the study. One patient was discharged from the hospital before the end of the AAT program. The other patient exhibited behaviors that threatened to compromise the welfare of the therapy dogs, and therefore stopped participating in the AAT activity (See Effigy ​ i ).

Schizophrenic Symptomatology (PANSS)

At the end of the program, no significant differences were found between control and AAT-treatment groups (Mann–Whitney U test, p < 0.05) with respect to final PANSS or change in PANSS (see Tabular array ​ 3 for full details). However, there were significant differences in PANSS pre-treatment and mail-treatment scores in both command and AAT-treatment groups (t-test; p < 0.05). In the AAT-handling group, scores for all PANSS subscales (positive, negative, and general) were significantly lower after the AAT programme (t-test; p < 0.05). In the command group, only positive and general PANSS scores showed a significant decrease later on handling (t-exam; p < 0.05). For full details, see Table ​ 4 .

Table three

Differences betwixt control and treatment groups with respect to last PANSS (after 6 months of handling) or modify in PANSS.

	Mean (SD)
	Treatment (N = 14)	Command (N = 8)	U	Z adapted	2 sided verbal p ∗
PANSS positive score FINAL	xiii.half-dozen (three.viii)	12.9 (5.ii)	52	0.24	0.81
PANSS positive modify	5.3 (iv.viii)	7.9 (4.3)	38.5	1.xvi	0.23
PANSS negative score FINAL	19.six (7.0)	nineteen.9 (5.four)	55	−0.03	0.97
PANSS negative change	−11.7 (7.4)	−8.9 (4.viii)	41	−0.99	0.33
PANSS general score Last	34.3 (eight.vi)	thirty.0 (6.0)	37	1.26	0.21
PANSS general score change	five.six (eight.9)	1.9 (3.4)	45	0.71	0.48

Table 4

Differences in PANSS pre-handling and post-treatment scores in both control and handling (AAT) groups.

Grouping	Variable	Number of pairs (pre vs. post)	Mean (SD)	t (df)	p-value
Control	PANSS positive	8	vii.87 (4.29)	t(seven) = 5.19	0.001∗
Command	PANSS negative	eight	1.87 (3.44)	t(7) = 1.54	0.167
Command	PANSS general	8	12.63 (13.57)	t(7) = 2.63	0.033∗
AAT	PANSS positive	14	5.28 (four.78)	t(13) = 4.xiii	0.001∗
AAT	PANSS negative	14	5.64 (8.19)	t(thirteen) = two.57	0.022∗
AAT	PANSS general	14	10.00 (viii.seventy)	t(13) = four.xxx	0.001∗

Quality of Life (EQ-5D)

No significant departure was found between AAT-treatment and Control groups (Isle of mann–Whitney U exam; p < 0.0025 later on Bonferroni correction). In add-on, most none of the EQ-5D items were significantly different after treatment (Wilcoxon test; p < 0.05; Tabular array ​ 5 ). Only the score for the general wellness item (compared with 12 months before) of the EQ-5D was significantly lower after the program in the AAT-treatment grouping (Wilcoxon examination; p < 0.05). For this item, depression scores betoken college health status, meaning that AAT-handling group patients perceived themselves to be in a better state of health afterward the program. Still, after applying a Bonferroni correction none of the results of EQ-5D was pregnant dissimilar subsequently treatment (for eight comparisons, p = 0.05/8 = 0.0625).

Table 5

Differences in EQ-5D pre-treatment and post-treatment scores in both control and handling groups.

Group	Variable	Number of pairs	Type of exam	t (df) or W	p-value
Control	EQ-5D Full score	8	T	t(7) = 1.eight	0.11
Control	EQ-5D Health today 12 m	8	W	W = 9	0.53
Control	EQ-5D Mobility	eight	West	W = 0	>0.99
Command	EQ-5D Pain/discomfort	8	W	W = 3	0.50
Command	EQ-5D Health Country today	viii	West	West = 0	>0.99
Control	EQ-5D Anxiety/Depression	8	Westward	W = −three	0.fifty
Control	EQ-5D Daily Activities	viii	W	W = −1	>0.99
Control	EQ-5D Personal Care	8	∗∗	∗∗	∗∗
Treatment	EQ-5D Total score	14	W	W = −3	0.91
Handling	EQ-5D Health today 12 chiliad	14	W	Due west = 37	0.03∗
Treatment	EQ-5D Mobility	fourteen	∗∗	∗∗	∗∗
Handling	EQ-5D Pain/discomfort	xiv	W	West = −three	0.76
Treatment	EQ-5D Wellness State today	14	W	W = 0	>0.99
Handling	EQ-5D Feet/Depression	fourteen	W	W = 0	0.34
Treatment	EQ-5D Daily Activities	fourteen	W	W = −10	0.07
Handling	EQ-5D Personal Intendance	fourteen	West	W = 3	0.34

Adherence to Treatment

Although patients were encouraged, and expected, to nourish all scheduled activities, attendance was entirely voluntary. In the AAT-treatment group, there was an overall 92.nine% (SD = 4.seven) adherence to treatment for the AAT sessions. The bulk of absences from the AAT sessions were due to family or health bug. Just one time did a patient not want to attend an AAT session. In the control group, there was an overall 61.2% (SD = 24.8) adherence to treatment for the assigned activity from the functional plan. This higher level of adherence to the AAT sessions, compared with overall adherence to the functional activities, was meaning [t-test: t(20) = 4.7; p = 0.0001]. We could just compare adherence to AAT-treatment with specific functional programme activities for which the number of attention patients was large plenty to justify a statistical examination (art therapy and gymnastics). AAT showed significantly better adherence than art therapy (Mann–Whitney U examination; U = 2; p = 0.01) and gymnastics therapy (Mann–Whitney U test; U = ii; p = 0.01). All detailed data on adherence to treatment are presented in Tables ​ 6 and ​ 7 and run into Figure ​ 2 .

Table 6

Patients' adherence to treatment.

Patient ID	Group	Number of programmed sessions	Number of attended sessions	Percentage of adherence
1	Treatment	40	38	95
2	Treatment	twoscore	37	92.5
3	Treatment	40	39	97.5
4	Treatment	twoscore	40	100
five	Treatment	twoscore	37	92.five
6	Handling	40	34	85
vii	Handling	40	39	97.5
eight	Treatment	40	36	90
ix	Treatment	xl	37	92.5
10	Treatment	40	38	95
11	Treatment	40	37	92.five
12	Treatment	40	34	85
13	Handling	40	39	97.five
14	Treatment	40	35	87.five
15	Control	28	16	57.1
16	Command	28	half-dozen	21.4
17	Command	28	13	46.iv
eighteen	Command	21	18	85.vii
19	Control	28	25	89.3
twenty	Control	28	18	64.3
21	Control	56	22	39.3
22	Control	56	48	85.7
Mean(SD)	All patients	37.9 (8.iv)	31.1 (10.1)	81.3 (21.5)
	Treatment grouping	40.0 (0.0)	37.1 (i.ix)	92.9 (4.7)
	Control grouping	34.1 (13.vii)	20.8 (12.4)	61.2 (24.viii)

Table vii

Differences in adherence to treatment between AAT and other types of functional rehabilitation interventions.

Type of compared functional intervention	Number of participants in the control group	Type of examination	t (df) or U	p
AAT vs. Fine art therapy	iii	U	U = ii	0.010∗
AAT vs. Gymnastics	three	U	U = ii	0.010∗
AAT vs. Psychodynamic therapy	1	U	∗∗	∗∗
AAT vs. Grouping sport	1	U	∗∗	∗∗
AAT vs. all other	viii	T	t(20) = 4.7	0.001∗

Differences between AAT and other functional rehabilitation interventions.

Salivary Cortisol and Blastoff-Amylase

We collected 61 pre-session and sixty postal service-session saliva samples from the AAT-treatment grouping. However, some of the saliva samples were likewise small for analysis and were discarded. Cortisol analysis was performed with 48 matched pairs of samples (matching every corresponding pre-session and mail-session sample for each session for which sufficient sample was available). There was a significant decrease in cortisol later participation in an AAT session (Wilcoxon Test; p < 0.05. Pair-matching was confirmed using the Spearman exam; p < 0.05). Fifty pairs of matching samples were used to measure the effect of the intervention on salivary alpha-amylase. sAA was increased after the AAT sessions, but the difference was not quite significant (Wilcoxon Examination; p = 0.059. Pair-matching was confirmed using the Spearman test; p < 0.0001).

Discussion

In terms of historic period and gender, our sample of patients was consistent with the general population of people with schizophrenia, also as the population of institutionalized people with schizophrenia (Jablensky, 2000; Uggerby et al., 2011). All participants were receiving at least one psychotropic drug, as is common in people treated for this condition (Jablensky, 2000; Uggerby et al., 2011). Our results could therefore be relevant to other similar institutions that are considering the implementation of an AAT plan.

With regard to population size, our written report was comparable with like studies that have investigated the consequence of AAT in the treatment of schizophrenia, suggesting some mutual methodological limitations (Barak et al., 2001; Nathans-Barel et al., 2005; Kovács et al., 2006; Berget, 2008; Chu et al., 2009; Villalta-Gil et al., 2009). Apart from the constraint of working with a limited full population of patients inside a single infirmary unit, and the awarding of exclusion/inclusion criteria, it should be remembered that AAT has to be conducted in small groups for practical reasons such as the need for proper supervision and a high fauna-to-patient ratio (Fine, 2010).

One patient withdrew from the report due to the adventure of damage to the therapy dogs. This kind of problem should take been anticipated and taken into account inside the exclusion criteria. This should be considered in future studies. Another patient withdrew very early in the study (week three), and prior to the collection of whatever outcome data. The recommended approach for superiority studies is an intention to care for analysis, whereby all patients included in the randomization are included in the analysis, and by deviating from this approach in our study nosotros risk an overestimation of the treatment effect (Armijo-Olivo and Magee, 2009). So, whilst the results are interesting and signal to a potential result of treatment, they cannot be relied upon every bit general show of efficacy in a clinical population.

People with a diagnosis of chronic schizophrenia who live in institutionalized settings have very low levels of social functioning and social activeness (Kovács et al., 2004). Individual or combined measures of symptomatology, quality of life and adherence to treatment are normally used to assess the efficacy of a psychosocial rehabilitation process for patients with schizophrenia (Wilson-d'Almeida et al., 2013), but not together in the aforementioned report. By including these measures and adding an assessment of salivary cortisol and alpha-amylase, our study provides an interesting insight into the utilise of combined measures.

In terms of symptomatology, in the AAT-handling group we observed an comeback in negative symptoms of schizophrenia like apathy, asociality, anhedonia and alogia, that could be partially explained by the regular interaction between patients and animals. Previous work suggests that AAT programs may exist effective in the control of negative symptoms of schizophrenia (Barker and Dawson, 1998; Barak et al., 2001; Kovács et al., 2004; Nathans-Barel et al., 2005). Therapy dogs have been described every bit social catalysts or mediators of interactions between patients and between patients and their therapists, and these benefits could be extended outside the AAT sessions (Fine, 2010). Since negative symptoms of schizophrenia are relatively insensitive to pharmacological therapies and are associated with a chronic course and loftier levels of social disability, it is very of import to find effective alternative interventions that can be added to standard handling protocols (Hammer et al., 1995; Liddle, 2000; Gråwe and Levander, 2001). The beneficial furnishings of AAT on negative symptoms of schizophrenia is therefore worthy of farther investigation.

The trend toward an increment in blastoff-amylase combined with the pregnant decrease in cortisol after the AAT sessions suggests that the interaction patients had with the dogs was perceived to exist not simply engaging, but also relaxing. Increases in alpha-amylase and the activation of the SNS can occur in positive emotional states (Fortunato et al., 2008; Payne et al., 2014), and recent research indicates that people with schizophrenia may experience a dysregulation of SNS tone (Monteleone et al., 2015).

The lack of significance for the change in salivary alpha-amylase could be due to the absenteeism of an effect, but also due to the small population size and the minor number of collected saliva samples (saliva was but nerveless for the last four AAT sessions, sample collection was not always successful, and approximately 17% of collected samples had to exist rejected due to inadequate sample volume for analysis).

Regarding stress and cortisol levels, previous inquiry has establish decreases in salivary cortisol during AAT sessions in other types of patients, such as autistic children (Viau et al., 2010) and insecure attached males (Beetz et al., 2012a). In a previous study with people being treated for schizophrenia, cortisol levels were not been found to change subsequently interaction with animals (Nepps et al., 2014). All the same, in comparing to our study, the AAT protocol for that study did non include repeated sessions for each patient and the ratio of dogs per patient was lower. Long-term and dose effects of AAT on stress levels of patients with schizophrenia notwithstanding need to be studied. Time to come studies could take reward of our experience past extending the measurement of salivary cortisol to all AAT sessions inside a plan, and a control group, while also looking for long-term and dose effects.

In that location were some difficulties in collecting saliva samples in this study, both in terms of quantity and quality of saliva. The pharmaceutical treatment of schizophrenia involves drugs that suppress salivation, and as a consequence of their symptomatology, many people with schizophrenia are smokers (Rae et al., 2014). Smoking increases cortisol and decreases alpha-amylase (Granger et al., 2007a), so this could be a confounding factor. Time to come studies should include data on patients' smoking level, particularly when comparison saliva measures betwixt groups, as betwixt group matching could be important. In addition, personal hygiene and dental care seems to exist poor in many people with schizophrenia (Velligan et al., 1997), and the presence of impurities in saliva samples could interfere with the reliability of the measurements (Granger et al., 2007b). Ideally, a patient should take rinsed his or her mouth with water some minutes before saliva collection, but due to a lack of patient cooperation this was rarely possible. Future research should try to extend and optimize saliva sample extraction and assay, as it seems cortisol and blastoff-amylase could exist good markers of AAT effects in people being treated for schizophrenia.

Quality of life measurements did not differ between pre-treatment and post-treatment atmospheric condition in either of the 2 groups. Improvement in symptomatology is non always related to improvement in quality of life in people with schizophrenia as the latter tin be affected by other factors such us the level of insight (Wilson-d'Almeida et al., 2013; Hayhurst et al., 2014; Margariti et al., 2015). Previous research has shown that even patients with schizophrenia who are undergoing handling can experience a progressive decline in their quality of life (Medici et al., 2015). Therefore, a lack of decline in overall quality of life measurements could be interpreted to exist a benefit of psychosocial rehabilitation, particularly in chronic patients. Future enquiry could focus on specific domains of quality of life where AAT seems to accept a direct effect, such as anxiety and depression (Barker and Dawson, 1998) and social relationships (Villalta-Gil et al., 2009).

In the present study, mean adherence to the alternative functional rehabilitation interventions (art therapy, group sports, dynamic psycho-stimulation, or gymnastics) was lower in the control grouping than the AAT-treatment. Previously reported adherence rates to therapeutic sport programs for people being treated for schizophrenia range from 50 to 82% (Beebe et al., 2005; Warren et al., 2011). In the present study, there were intrinsic differences between the activities included in the functional plan, merely they all shared sure features, such every bit frequency, duration, and being conducted outside the hospital. Although the added value of AAT sessions in terms of adherence could be due to a novelty consequence, attendance to sessions did not refuse during the program. Data about adherence is rarely reported in AAT inquiry, but it could exist a very useful indicator in the context of psychosocial rehabilitation, and deserves further research (Kamioka et al., 2014).

Another cistron that could be of importance in adherence to ATT is the human being–domestic dog human relationship (Nagasawa et al., 2015). An initial bond may be quickly established between a person and a dog, and this bail has a strongly emotional element (Dwyer et al., 2006; Fine, 2010; Beetz et al., 2012b), that leads to the development of attachment to the dog (Zasloff, 1996). This attachment could contribute to a person'southward sustained interest in attending AAT sessions, merely could potentially pb to problems when the human–animal bail is disrupted at the end of the program. Further research could monitor the development of the patient–canis familiaris bond during an AAT program, and the effects of catastrophe such programs.

Taken together, the various significant results reported in this report (reduction of negative symptomatology, high adherence to the AAT program, and cortisol reduction after AAT sessions) could be explained by the biological science of man–beast interactions (Beetz et al., 2012b; Nagasawa et al., 2015). When a person has a enjoyable contact with a dog there is a release of oxytocin, dopamine, and endorphins, too as a decrease in cortisol (Beetz et al., 2012a,b; Julius et al., 2013). This overall reaction seems to raise pro-social beliefs and decrease anxiety and stress, mainly via the hypothalamic-pituitary axis (HPA; Neumann et al., 2000). Oxytocin administration has previously been proposed as a treatment for psychiatric patients because of its broad pro-social furnishings on behavior and cognition (Zik and Roberts, 2014). Through the release of oxytocin, positive contact with dogs could produce such psychosocial and psychophysiological benefits. Future research in AAT might also effort to study changes in oxytocin levels of people beingness treated for schizophrenia during contact with animals.

The results of our study enhance some questions that could exist addressed in futurity work. Adherence to treatment is a significant problem, especially in lengthy rehabilitation programs with challenging patients. Information technology would be interesting to investigate whether the high level of adherence to AAT that we observed is replicated in other therapeutic situations, and whether adherence really is dissimilar from other closely matched activities. Information technology is possible that the mere presence of a dog in whatever type of therapy session could better adherence, peculiarly if the patient has developed a human relationship with the canis familiaris during AAT, and this effect should exist investigated. In all rehabilitation programs resources are limited and the inclusion of AAT could stand for an opportunity cost by displacing other activities. It is therefore important to find out whether patients who have participated in AAT go on to feel significant long-term benefits after the rehabilitation program has ended, compared with patients who have been involved in other activities.

Conclusion

Creature assisted therapy seems to be a worthwhile adjunct therapeutic approach for people being treated for schizophrenia in a conventional psychosocial rehabilitation process, with potential positive outcomes in symptomatology, adherence to AAT program, and stress reduction during AAT sessions.

Author Contributions

The newspaper itself was written by PC, JF, and JB. The paper was reviewed before submission past AB, JRF, SG, CM, OO, FM, AT, JC, and MG. All authors contributed to the initiation and design of the study. PC, JF, JRF, SG, CM, MG, and AB monitored the progress of the study. PC, JF, and JB decided on the analytic strategy. JB, JRF, SG and CM equally contributed to the full production of the study. PC is the guarantor of the study.

Disharmonize of Interest Statement

The Chair Analogousness Foundation Animals and Health is sponsored past a non-turn a profit Foundation (Analogousness Foundation). Any research The Chair Affinity Foundation Animals and Wellness develops is non related to any commercial product.

Acknowledgments

The authors are grateful to all of the patients, nurses, psychologists, psychiatrists and beast assisted therapy technicians. We would particularly similar to thank the following professionals and technicians who collaborated in this project: Rosa Cirac, Elena García, Ana Güimil, Natalia Iorlano, Miriam Pérez, Elia Sierra.

Footnotes

Funding. This study was supported past the Analogousness Foundation.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4858645/