To the Editor: Kopelowicz and associates (1) make incredible leaps of faith in the conclusions they draw from their study, published in the October 1998 issue, comparing two approaches to teaching community re-entry skills to clients with schizophrenia. The article has several errors of omission, in particular the lack of description of the "equally intensive" occupational therapy intervention used with the control group. The authors fail to describe what constitutes this intervention other than that it "included the full range of customary occupational therapy activities."
I am an occupational therapist who has practiced for 14 years in psychiatry, and I could only guess at what that statement means. Furthermore, there is no mention in the article of the occupational therapy assessment and identified goals for intervention, no mention of the therapeutic means used to achieve these goals, nor any description of whether the occupational therapy intervention was, in fact, designed to target the study goals.
Second, the title implies and the abstract states that patients "can also meaningfully improve the continuity of their own care by participating in a brief and highly structured training program." Yet the study results do not support that contention. It is a stretch of the imagination for the authors to assume that any relationship between skills training and one outpatient visit is evidence of achievement of the educational objective of community re-entry. Further, the authors' claim that an initial outpatient visit is evidence of "a substantial and meaningful difference in patients' following through with their aftercare" is lacking description, measurement, and support in the methods, results, or discussion sections.
Third, the authors did not control for the fact that the study participants were discharged to a variety of residences. Perhaps those who resided with their families were more inclined to attend their first aftercare appointment, perhaps some of the participants were linked with case management at discharge, or perhaps some were more inclined to make the first appointment because the last two sessions stressed the importance of doing so. The fact that many potential variables were unaccounted for, combined with the absence of information about the focus and intervention of the occupational therapy control group, makes it illogical for the authors to comment on a comparison between the two groups.
Fourth, the authors went to great lengths to describe the rigorous methods employed to train their trainers. Yet information on initial aftercare attendance was obtained by reviewing service records of scheduled sessions. There is nothing objective about clinical notations, unless the authors provided the outpatient clinics with a standardized format for reporting. If they did so, it was not mentioned in the article.
In summary, the article would have been more useful to its intended audience if the authors had included a fuller description of the occupational therapy intervention; had more explicitly described the limitations and weaknesses of their design with respect to generalization and meaningful differences; had accounted for, if not controlled for, the many variables that might have influenced the study's results; and had more carefully drafted their abstract and conclusions so as not to misconstrue their results.
Ms. Rebeiro is a clinical researcher with Network North, a community mental health group in Sudbury, Ontario.