Evaluation of independent living skills and social behavior of patients discharged from psychiatric hospitals

Abstracts

INTRODUÇÃO: Este estudo teve como objetivo avaliar o comportamento social e as habilidades de vida independente de um grupo de pacientes psiquiátricos antes de sua saída do hospital e 2 anos após a sua transferência para as residências terapêuticas. MÉTODO: Estudo de corte transversal, realizado em duas etapas distintas, antes e depois, utilizando-se, como instrumentos, as escalas Independent Living Skills Survey e Social Behavior Scale. RESULTADOS: A maioria dos pacientes era do sexo masculino (58,7%), com médias de idade e tempo de internação iguais a 57,5±11,8 anos e 29,8±10,2 anos; 54,6% tinham diagnóstico de esquizofrenia; 25,3%, de deficiência mental; e o restante, de categorias várias. Houve melhora significativa no comportamento social e no grau de autonomia dos pacientes (p <0,05) ao se comparar os escores dos pacientes nas escalas, nas fases 1 e 2. As variáveis que mais se associaram com o escore de evolução foram idade, tempo de internação e nível inicial de funcionamento dos pacientes. DISCUSSÃO: As limitações no funcionamento social e no grau de autonomia dos pacientes, na primeira fase do estudo, não foram incompatíveis com a convivência na comunidade. Os pacientes apresentaram evolução satisfatória no comportamento social e nas habilidades cotidianas ao longo de 2 anos, de acordo com os escores de evolução medidos pelas duas escalas.

Desinstitucionalização; comportamento social; atividades cotidianas

ORIGINAL ARTICLE

Evaluation of independent living skills and social behavior of patients discharged from psychiatric hospitals

Carlos Eduardo Leal Vidal^I; Eliane Costa Dias Macedo Gontijo^II; Marina Bittencourt Bandeira^III

^IPsychiatrist, Centro Hospitalar Psiquiátrico de Barbacena, Fundação Hospitalar do Estado de Minas Gerais (FHEMIG), Belo Horizonte, MG, Brazil. MSc. Assistant professor, Faculdade de Medicina de Barbacena, Barbacena, MG, Brazil

^IIPhysician. PhD in Tropical Medicine. Associate professor, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil

^IIIPsychologist. Post-doctorate in Psychology, Université de Montreal, Montreal, Canada. Associate professor, Mental Health Research Laboratory, Universidade Federal de São João Del Rei, São João Del Rei, MG, Brazil

Correspondence

ABSTRACT

OBJECTIVE: This study aimed at assessing social behavior and independent living skills in a sample of psychiatric patients before their discharge from a mental hospital and after 2 years living in community facilities.

METHOD: A cross-sectional study was carried out in two stages using the Independent Living Skills Survey and the Social Behavior Scale.

RESULTS: Most patients were male (58.7%). Mean age and hospitalization time were 57.5±11.8 and 29.8±10.2 years, respectively; 54.6% were schizophrenic, 25.3% had mental retardation and the remainder had different diagnoses. There was significant improvement in patients' social behavior and level of autonomy (p < 0.05), as evidenced by comparison of their scores in stages 1 and 2. Hospitalization time, age and baseline score were the variables with the most consistent association with evolution scores.

DISCUSSION: Patients' impairments in social role functioning and autonomy levels before their discharge from a mental health hospital were not incompatible with living in society. Patients showed great improvement in social behavior and level of autonomy after 2 years, defined by evolution scores measured by both scales.

Keywords: Deinstitutionalization, social behavior, activities of daily living.

Introduction

Implementation of new care modalities in the process of Brazilian psychiatric reform points to the need of evaluation of these services and obtained results, aiming to maintain their quality. Follow-up of these patients in the community represents a challenge for mental health public policies, since it requires structures of social support and services of permanent rehabilitation, due to patients' difficulties in performing everyday situations and in social relationships.^1-3 In this context, the objective of treating patients with severe mental disorders in the community considers not only symptom reduction, but also focuses on improvement of social functioning and performance of roles.⁴

The World Health Organization (WHO)⁵ has recommended an integrated permanent and periodic evaluation of mental health services and programs, including the perspective of professionals, relatives and patients.⁶ With regard to effects on patients, it is important to particularly evaluate satisfaction with the service, quality of life, degree of autonomy, social behavior and psychiatric symptoms.⁵

Most investigations on the impact of programs of social reinsertion for psychiatric patients and on the indicators of mental health is based in international studies and, despite the similarities between health problems in different countries, there are doubts as to the feasibility of generalizing research results. Therefore, there is a need of performing, in the Brazilian context, researches that contribute to the planning of actions required to reinsert patients in the community.

A more objective evaluation of these parameters can be performed by using standardized and validated measurement instruments, which provide higher data reliability and allow comparison between studies. Concerning patients discharged from hospitals, evaluation helps both in identification of limitations that should be the object of interventions and in monitoring the effects of social insertion programs in their lives.^6,7

In Brazil, WHO scales to evaluate satisfaction by users⁸ and relatives⁹ with mental health services have been validated, as well as scales to evaluate professionals' satisfaction and overload in respective services.^6,7 Other scales validated for the Brazilian context are a scale of relative overload in caring psychiatric patients,¹⁰ a scale to evaluate social behavior,¹ inventory of independent living skills^11,12 and scale of quality of life for patients with schizophrenia.¹³

In this context, some studies have been developed on quality of life of psychiatric patients,^13-16 their level of everyday functioning, degree of satisfaction with services¹⁷ and limitations observed in social behavior and level of autonomy for independent living skills.^2,18,19 These studies contribute to the planning of actions required to reinsert patients in the community.^1,2,11,18 However, none of the studies above compared the data obtained before and after patients being discharged from hospitals.

This study aimed at evaluating psychiatric patients who were discharged from hospitals and are currently inserted in the community, living in therapeutic residences (TR). In addition, our intention is to compare the results with those obtained in a previous survey, performed before the patients were discharged from hospitals, aiming to evaluate the evolution of patients concerning levels of social behavior and independent living skills.

Method

Type of study

This study is a non-compared cohort study, in which independent living skills and social behavior of a sample of psychiatric patients were evaluated before being discharged from hospitals and 2 years after their transference to TR.

Study site

This study was carried out in Barbacena, a municipality located in the State of Minas Gerais, Brazil, with a population of 125,000 inhabitants, known for many years as the "city of madmen," due to the high number of patients hospitalized in psychiatric hospitals. When the study was started, there were almost 1,000 patients hospitalized in five different hospitals in that municipality. Of these, about 90% had been hospitalized for approximately 30 years.

The first research stage was performed with inpatients in two psychiatric hospitals, 1 month before being discharged and transferred to the TR. One of the hospitals selected for the present study was Sanatório Barbacena, with capacity for 120 beds to provide care for both genders. After being disaccredited by the Brazilian Unified Health System, by the end of 2003, it had its patients transferred to other hospitals or to TR. The second hospital was Centro Hospitalar Psiquiátrico de Barbacena (CHPB), a public state hospital, with capacity of 350 beds, which started its process of discharging patients in accordance with Edict 52, January 2004.²⁰ The second study stage was performed at TR, which are houses inserted in the community and destined to provide care to patients coming from long-term psychiatric institutions.

Sample

The sample included 75 chronic patients, 30 (40%) from Sanatório Barbacena and 45 (60%) from CHPB, and was taken from a universe of 150 patients who were under the process of being discharged. The criteria adopted in the selection of patients that would be discharged were established by a mental health team external to our research, comprised of professionals of both hospitals and of the Municipal Department of Mental Health. Once the number of residences to be formed was defined (20 TR), a survey of clinical and psychiatric conditions of patients with long hospitalization time was performed, also investigating existence of family bonds and social security status. Since it was a new proposal and there was not a clear definition of the profile of a patient candidate for TR, we chose to select those with the highest degree of independence and that had a stable psychiatric status. The number of subjects interviewed in this study was limited to 75, due to the rhythm of hospital discharge, since the first evaluation had to be performed before patients were discharged. Therefore, it is a convenience sample, in which procedures and circumstances of hospital discharge were used.

Information about sample characteristics regarding sociodemographic variables, psychiatric diagnosis (International Classification of Diseases - ICD-10) and drugs used in both research periods were obtained from the patients' medical charts. Daily dose of each antipsychotic was converted into an equivalent standardized dose of chlorpromazine.^21,22

Evaluation instruments

Two measurement instruments validated to Brazil were used, as described next.

Independent Living Skills Survey (ILSS)

This scale was adapted and validated to Brazil by Lima et al. ¹² and Bandeira et al. ¹¹ based on the original scale developed by Wallace in 1986.²³ It has 86 items evaluating autonomy of chronic patients in nine areas of everyday life, in terms of frequency with which they have the basic skills to be independent in the community. These areas are eating, personal care, household activities, preparation and storage of foods, health, leisure, money management, transportation and employment. Scores range from zero to four. Zero means the lowest degree of autonomy, and four indicates the highest degree. The validation study of the Brazilian version pointed satisfactory psychometric qualities of validity and reliability regarding internal consistency of its subscales, test/retest temporal stability, as well as discriminating validity and construct validity.^11,12

Social Behavior Schedule (SBS)

This scale is the Brazilian version validated by Lima,¹ based on the original scale developed by Wykes & Sturt.²⁴ SBS has 21 items evaluating limitations of social behavior in long-term patients, both in psychiatric hospitals and in residential services in the community, with scores ranging from zero (absence of problem) to four (severe problem).

The items in the original scale were grouped, using a factor analysis, into five subscales by Wykes et al. in 1982:²⁵ social isolation (items 1, 18, 19), embarrassing social behavior (items 2, 3, 4, 9, 11, 16, 20), depression and anxiety (items 6, 7, 8, 15), hostility and violence (items 5, 14) and unacceptable social behavior (items 12, 13, 17, 21). Item 10 was not included in any category, since it reached a value lower than that established by the authors in factor analysis. Validation of the Brazilian version was performed in 2003 and had satisfactory psychometric qualities of validity and reliability concerning internal consistency of its 21 items.¹

Procedures for patient evaluation

Scales ILSS and SBS were filled based on the information obtained from a member of the mental health team that followed the patient's behavior. Such information refers to the patient's behavior in the month prior to the interview. In the first research stage, the scales were applied by two psychologists in interviews with the aid of the nurse in charge of patient care. The interviewers had been previously submitted to a training, which consisted of reading and discussing articles on the measurement scales, as well as supervised application of the instruments. Firstly, the raters watched application of the scales by the project author; next, they applied the scales in a pilot study, being directly observed during the interviews. In the second research stage, both scales were applied by the project author, in interviews performed with the patient's caretakers in TR.

The interviews followed a standard procedure in both research stages. All the interviewees were submitted to the same procedures, aiming to follow the application criteria of the questionnaires used in validation studies.^1,12

Data analysis

Global and subscale scores were computed for both instruments. A dependent variable was created, called "evolution score," to evaluate the evolution of patients concerning social behavior and daily living skills, resulting from the difference between initial and final scores in both scales, i.e., before and after being discharged. The Wilcoxon rank-sum test was used to compare these evolution scores. Pearson's correlation coefficient was used to evaluate correlation between scores obtained by the patients in both scales, that is, the relationship between their evolution in degree of autonomy and psychosocial functioning. McNemar test was used to analyze percentage data of patients who had behavioral problems before and after being discharged.

Univariate and multivariate analyses were performed to evaluate factors associated to the evolution observed in patients in scale scores. Mann-Whitney test was used for dichotomic variables, such as gender and diagnosis. Pearson's correlation coefficient was used to analyze the influence of continuous variables (age, hospitalization time and drugs) in evolution scores. The model of multiple linear regression was used for multivariate analysis. Confidence level was set in 95%. The SPSS software, version 12.0 was used to store and process data.

Ethical considerations

This research was approved by the research ethics committee at Fundação Hospitalar do Estado de Minas Gerais and Universidade Federal de Minas Gerais. All the interviewees signed an informed consent term before answering the questionnaires.

RESULTS

Profile of participating patients

There was prevalence of male patients (58.7%), age ranged between 31-88 years, mean of 57.5 years and standard deviation (SD) of 11.8. Mean hospitalization time ranged between 2-64 years, with mean of 29.8 years (SD = 10.2).

As to diagnosis, 54.6% had schizophrenia and other psychotic disorders; 25.3% had mental deficiency; 8% had epilepsy; 5.3% had bipolar disorder; and 6.8% had nonspecific mental disorders. In the first study stage, the equivalent daily dose of chlorpromazine used by the patients ranged between 25-1,050 mg/day, with median of 75 mg. One patient was taking atypical antipsychotics, and 24 (32%) were not taking antipsychotics. In TR, daily dose of chlorpromazine ranged between 25-750 mg, with median of 75. Two patients were taking atypical antipsychotics. The number of patients that were not taking any drug remained unchanged. There was no association between use of antipsychotics and SBS and ILSS scores, considering all patients and each diagnostic category.

Social behavior

Figure 1 shows the percentage of patients with problems in social behavior, in the three items that had more frequency and in the three items with the lowest frequency, of all 21 items evaluated by the SBS in both study stages. There was reduction in the percentage of patients with social behavior problems in the second stage in relation to the first evaluation (p < 0.05).

Table 1 shows medians of scores obtained in the SBS scale, in both research stages, and medians of the difference between these scores, which consists of the evolution score, showing significant improvement in the patients' social behavior.

Table 1- Click to enlarge

Results of univariate analysis showed significant effects of diagnosis, age and hospitalization time. Comparison of evolution scores of social behavior in terms of diagnosis showed that schizophrenic patients had better evolution on global score and in subscale of social isolation in relation to patients with other diagnoses. There was no difference between genders.

In the analysis of evolution scores in relation to continuous variables, the lower the hospitalization time, the higher the evolution score. That result was obtained both in global scale and in relation to subscales embarrassing behavior, depression and anxiety and unacceptable social behavior.

Factor age was equally correlated with evolution score of global scale and subscales of depression and anxiety and unacceptable social behavior. For the variable use of neuroleptics, there was no significant correlation with evolution scores of social behavior.

Results of the multivariate regression analysis, shown in Table 2, showed the variables that were retained in the final model of evolution scores of social behavior. Evolution of patients as to social behavior, before and after being discharged, was a function of variables hospitalization time, diagnosis and gender. The variable hospitalization time was inversely associated with improvement in global score and in subscales depression and anxiety, embarrassing behavior and unacceptable social behavior.

Table 2 - Click to enlarge

Patients with schizophrenia had significantly higher improvement in subscale social isolation, when compared to the other patients. Female gender showed significantly higher improvement in embarrassing behavior and was the only variable, along with hospitalization time, that remained in the final model for that category.

Inclusion of initial score of social behavior as an explanatory variable, in the regression model, significantly increased determination coefficient (R²) in the global scale and in all subscales. With that inclusion, coefficient ranged between 53-83%, indicating better adjustment in the regression model. Patients who had higher initial scores, i.e., worse performance in social behavior, were those who had the highest evolution scores. However, this score was such a significant variable that prevented the other variables from remaining in the model.

Independent living skills

As to degree of autonomy in the first research stage, there was an important limitation by patients in everyday living skills. Patients had better performance only in the subscale related to eating and, at a lower degree, in the subscale of personal care. In global score and other subscales, patient had low scores (Table 3). Subscales regarding preparation of foods, money management and employment were not evaluated in this stage, since the patient had no opportunity of performing such activities while hospitalized.

Table 3 - Click to enlarge

In the second stage, there was significant improvement in the scores of almost all subscales, as can be observed by the evolution scores presented in Table 3. The two subscales that were evaluated only in this stage, concerning skills of food preparation and money management, obtained low scores (1.95 and 1.33, respectively). The subscale of skills regarding employment was not evaluated in the second stage either, due to absence of performance in this domain.

Table 4 shows the results of multivariate analysis. It can be observed that introduction of ILSS initial score as an explanatory variable significantly increased R² coefficient. Except for the subscale related to leisure, initial score was inversely associated with evolution scores in other subscales. That means that the lower the score and, therefore, the lower the degree of autonomy in the first stage, the higher the patient's improvement.

Table 4 - Click to enlarge

Multivariate analysis showed that the evolution degree of patients' autonomy, before and after discharge, was correlated with hospitalization time, diagnosis, age and gender. Hospitalization time was positively associated with the scores of global evolution and subscales concerning eating, personal care, household activity and health care, therefore, more evolution for patients with longer hospitalization time. Patients with schizophrenia had better performance in domestic activities than the others. Female gender had better evolution in the eating subscale. Variable age was inversely correlated with evolution score in the global scale and in the subscales related to health, transportation and leisure.

Other results obtained, but not included in the tables, are described next. The performances of patients living in houses that have a night caretaker or not were compared, and results showed that houses without caretakers were those where there was better evolution of patients as to ILSS global score.

Correlation coefficient of scores between ILSS and SBS scales in the first stage was 0.44 (p = 0.01), and 0.62 (p = 0.01) in the second stage.

Discussion

Comparison of patient scores in the SBS scale in both study stages showed significant improvement in the patients' social behavior in all subscales. In the hospital stage, the most affected areas were observed in items personal appearance and hygiene, communication and social interaction. These results are very close to those obtained in three studies performed in Brazilian psychiatric hospitals^2,19,26 and are expected in patients with long-term hospitalization and no social bonds. On the other hand, in the present study there was low prevalence of disabilities in areas that could result in problems or risks for patients or for the society, such as inadequate sexual behavior, violence or suicidal thoughts. Low scores in these areas may favor the discharge process.¹⁹

As to the scores obtained by the ILSS, most patients had considerable limitation in the first assessment, before being discharged. The questions of that scale, which include both household and social skills, cover activities that patients had little or no opportunity to perform at the hospital. Low scores observed in subscales of health cares and household activities, for example, can be related to the fact that these activities, in most hospitals, are performed or supervised systematically by employees, which impairs the development of patient autonomy. However, some skills, concerning subscales eating and personal care, are continuously encouraged, aiming at patient independence in these areas.

After living in the community for 2 years, the patients had significant improvement in scores of almost all ILSS subscales evaluated in this stage. Even so, in some areas, performance is still low, requiring continuous training, for instance, in the subscale health care. In addition, skills concerning preparation of foods and money management, which were not evaluated in the initial stage, had low scores in the second stage, which indicates need of more training and permanent monitoring.

Despite covering different aspects of the patient's life, both scales used in this study had significant correlation between themselves as to scores obtained in the first and second stage. This result indicates that there is an association between improvement in social behavior and development of patient autonomy, suggesting that they are two associated classes of behaviors, and not independent classes in the individual's repertoire.

There was no significant association between variables gender, psychiatric diagnosis and medication and evolution of global scores obtained in SBS and ILSS scales. Only the factor hospitalization time was associated with evolution score in both scales. Such association, however, was different for the data in both scales. With regard to social behavior, the best evolution was obtained by patients with less hospitalization time and who had behavioral problems, as indicated by higher initial score. The opposite occurred for independent living skills. Patients with longer hospitalization time had better evolution. However, only those who had lower initial scores, i.e., less autonomy, had improvement in those skills. These results indicate, therefore, that independent of hospitalization time, more marked improvements were associated with worse initial performances in both scales.

In the project Team for the Assessment of Psychiatric Services (TAPS),^27,28 problems in social behavior of 670 discharged patients, evaluated by SBS, had no significant changes through time, neither in total score, nor in the subscore related to negative symptoms. Contrasting with SBS, there were significant changes in daily living skills. The patients acquired skills to use community services, in household activities and increased proportion of social contacts. Variables age and initial score were most strongly associated with observed changes. Elderly patients had higher reduction in psychiatric symptoms, but worse performance in acquisition of household and social skills. A group of more severe patients, with previous aggression problems or sexuality disinhibition, had gain in daily living skills and reduced behavioral problems in 50% after a 4-year follow-up.²⁹

In this study, variable age was inversely associated with better ILSS global evolution scores. It is possible that younger patients are better to retain essential social skills for an independent life and to establish contacts in the community, besides maintaining cognitive ability to adjust to environmental changes. These variables can be considered as intervening factors that act to enhance the potential of discharge effect and life in community residences, which allow training of living skills and social behavior by involving professionals in everyday activities.

Priebe et al.³⁰ compared two groups with around 60 patients each, the group of discharged patients being comprised of younger patients with lower hospitalization time. After 1 year, the group living in the community had significant change regarding their quality of life and less number of needs, when compared with the hospitalized group.

As to psychiatric diagnosis, patients with schizophrenia in the present study had improvement in subscales of social isolation in SBS and household activities in ILSS, with tendency of improvement in global score in ILSS. Recent evidence suggests that elderly patients with schizophrenia can maintain a high level of independence.³¹ Training of social competence has been efficacious in helping these patients acquire and maintain the skills needed to their social reinsertion.³

Presence of deficiencies in social functioning is a characteristic of schizophrenic patients. Such deficits include difficulties in terms of relationships, work, self-care and participation in leisure and community activities. The main factors associated with that impairment are presence of negative symptoms and cognitive deficits^32,33 and, regarding discharged patients, isolation imposed by long hospitalization time.³⁴ Due to status chronicity, changes in behavior and acquisition of skills by patients are not always expressive.^35,36

There was reduction in mean dose of neuroleptics between both stages. However, there was no association between use or dose of antipsychotics and variation in final scores in both scales. These results are in agreement with those obtained by Ryu et al.³⁷ After a 2-year follow-up of discharged patients, those researchers did not observe change in total dose of prescribed neuroleptics, suggesting that improvement seen in psychiatric symptoms could be a result of changing the treatment site and an effect of interventions.

Szmidla & Leff³⁸ did not observe relation between these variables either, after following a group of schizophrenic patients for 2 years and evaluating the effects of drugs and psychosocial interventions on psychiatric symptoms. The authors observed that introduction of atypical antipsychotics was significantly associated with improvement in delusional symptoms, but had no effect on hallucinations and negative symptoms, which responded better to psychosocial interventions. Besides discriminating the effects of both interventions, they concluded that observed improvement could not be only a result of passage of time, but an effect of interventions. Interpretation of results in the above study is complex, since it is difficult to determine the components of interventions that are responsible for the effects. Factors related to patients, such as severity of symptoms and time of disease, and factors related to professionals, such as training and interest, may interfere with results.

Transference of cares from the hospital to the community alone does not assure change in patient performance. Organization of the service, training for the staff and rehabilitation interventions represent factors that are directly related to changes observed in patients, independent of degree of previous psychosocial limitation.³⁹ Environments that are less restrictive and have more privacy provide better opportunities for a normal rhythm of life and facilitate the process of social reinsertion.⁴⁰

Another important characteristic to assure the success of patients' reinsertion is access to a community environment that encourages their participation in everyday activities and in the organization of household chores, according to an individual plan of skills to be developed.^40,41 Patients who have more access to community services have more possibilities of performing social interactions and learning what is practical.⁴² In residences where this type of encouragement is not present, patients are more passive and inactive; consequently, they do not develop basic skills for community life.⁴⁰

In the present study, high mean age and long hospitalization time were not incompatible with discharge and TR coexistence. With regard to social behavior, even with limitations, most patients had few problems, showing that they have conditions to live in the community. As to degree of everyday skills, patients had reasonable general performance, but needed follow-up and rehabilitation in some everyday activities. For those who had lower evolution, it is necessary to establish more specific programs. Improvement achieved by discharge can be partly confirmed by the fact that, after approximately 2 years living in the community, 30 patients are living in seven centers that no longer have a night caretaker. These patients are currently living in satisfactory conditions of independence and autonomy.

Conclusion

Some limitations of this study deserve to be stressed. Firstly, the number of participants and the fact that a convenience and non-probabilistic sample was used, limiting generalization of results. Another limitation is that the scales were applied by different raters in both study stages. However, cares were taken as to training and supervision of the interviewers, aiming to assure standardization in questionnaire application. In addition, there were different informers in both project stages, who could have different expectations as to discharge. Such variation could have contributed to observed differences. Lack of a comparison group, composed of patients who remained hospitalized, is another limitation. However, due to ethical reasons, it is not admissible to maintain a hospitalized comparison group with patients that are able to be discharged, with the aim of controlling this variable.

Despite these limitations, we expected that our results can be used as initial step of a continuous process of research in this area, due to the relevance of this theme in the current context of Brazilian psychiatric care. Other studies, including a higher number of patients, in varied locations and using different study designs, need to be developed to investigate the impact of discharge in social reinsertion of psychiatric patients.

This study particularly contributed to evaluating performance of psychiatric patients, before and after being discharged and transferred to TR, using validated measurement scales. Significant improvement observed in patients in most scale items confirms the feasibility of discharging patients and the importance of TR to allow patients' social reinsertion. Our results corroborate those obtained by other studies, despite the differences in terms of sample, methodology and location, confirming that patients with long-term hospitalization can live in supervised community environments and benefit from discharge.

Direct observation of patients in TR during this research also allowed access to valuable additional information as to patient improvement, which complement the data obtained by both scales. The patients had a wide variety of performances, developed over 2 years living in the community. The patients go out on dates, take professional courses, perform water exercises in gyms, travel and learn to use automatic teller machines.

Results suggest, therefore, that TR are a proper modality of community service for patients coming from a long hospitalization period. Despite deficiencies presented by some patients, transference of treatment site, along with rehabilitation programs, proved to be satisfactory for most of them. More expressive changes are expected to be detected with continuous follow-up of these patients. However, it is important to remember that TR are not exactly a health service, but above all a residence, a home that encourages social coexistence, freedom and construction of new possibilities, thus being different from other substitutive services.⁴³

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Publication Dates

• Publication in this collection
  31 Mar 2008
• Date of issue
  Dec 2007

History

• Received
  12 July 2007
• Accepted
  24 Sept 2007