Leisure-Based Interventions in Adults with Schizophrenia: A Scoping Review

Introduction

Schizophrenia is a severe mental disorder characterized by psychosis, apathy, social withdrawal, and cognitive impairment, which results in impaired functioning in work, school, parenting, self-care, independent living, interpersonal relationships, and leisure time (Geller, 1992). Approximately 24 million individuals worldwide, or 1 in 300, are affected by schizophrenia (World Health Organization, 2022). In adulthood, the corresponding rate is 1 in 222 (World Health Organization, 2022). The most common times for onset are in late teens and the twenties, and in men it happens earlier than in women (World Health Organization, 2022). Schizophrenia is one of the main mental health disorders contributing to the global disease burden, affecting different functioning domains, including social functioning (World Health Organization, 2012). People with schizophrenia have both internal and environmental obstacles to engaging in leisure activities, such as side effects from medicine, cultural stigma, family dynamics, and cultural norms (Rezaie et al., 2017).

Leisure is defined as a “non-obligatory activity that is Intrinsically motivated and engaged in during discretionary time, that is, time not committed to obligatory occupations such as work, self-care, or sleep” (American Occupational Therapy Association, 2014). Leisure plays a crucial role in a meaningful life for those with mental illness, offering benefits such as a strengthened sense of identity, self-belonging, active involvement, reduced boredom, and an effective method for managing stress (Iwasaki et al., 2014). However, leisure/recreational activities pose certain challenges. These involve finding, planning, and carrying out suitable and captivating leisure pursuits (Hein et al., 2020; Giacco et al., 2012). Depending on personal perceptions, leisure can be defined as either casual, serious, or project-based. It can take many different forms, such as instantaneous, brief, and intrinsically fulfilling activities without the need for special skills (i.e., casual leisure); systematic activities carried out by beginners or hobbyists with skills and expertise that could lead to a career itself (serious leisure); or occasionally short-term tasks completed as part of work obligations (project based leisure) (Stebbins, 2008).

Giacco et al. (2012) mention that “negative symptoms of psychosis may make it difficult for a person to participate in leisure activities”. Negative symptoms, such as apathy, anhedonia, and social withdrawal, can significantly hinder motivation and the ability to engage in enjoyable activities (Fervaha et al., 2014). These symptoms can create barriers to participation in leisure, which is essential for mental health recovery. Moreover, cognitive deficits, commonly associated with psychosis, further exacerbate these challenges. Impairments in memory, attention, and executive functioning can make it difficult for individuals with schizophrenia to plan, initiate, and sustain leisure activities. The combination of negative symptoms and cognitive deficits often leads to a reduction in leisure participation, depriving individuals of the therapeutic benefits of these activities, such as stress relief, social connection, and improved quality of life (Lepage et al., 2014; Fervaha et al., 2014). A study by Fervaha et al. (2014) found that cognitive impairment was a significant predictor of reduced engagement in leisure activities among individuals with schizophrenia. Another study highlighted how anhedonia and cognitive dysfunction jointly reduce the likelihood of pursuing pleasurable activities (Der-Avakian & Markou, 2012; Pisoni et al., 2021; Liang et al., 2022), which are critical components of leisure.

Addressing these issues through targeted interventions may enhance their engagement in leisure activities, contributing positively to their overall well-being. Preliminary research shows that active leisure as an intervention has been beneficial in schizophrenia (Lipskaya-Velikovsky et al., 2020; Snethen et al., 2012; Dean et al., 2014; Voruganti et al., 2006; Caddy et al., 2011). However, one study has been precise in inferring that people with schizophrenia participated in active leisure only when it was part of an intervention (Yanos & Robilotta, 2011). The above preliminary findings indicate that leisure-focused therapies could be crucial to achieving recovery oriented results (Iwasaki et al., 2014). Thus, our study aimed to explore the existing literature related to leisure-based interventions for adults with schizophrenia by identifying the findings of the existing studies and the impact and utilization of these interventions.

Methods

The framework proposed by scoping reviews by Arksey & O’Malley (2005) was used in the current scoping review.

Study selection

The search was carried out in the selected databases by two independent reviewers adhering to the established inclusion and exclusion criteria. Following title and abstract screening, the articles included for full-text screening were exported to an Excel sheet for blinding of the selection process. Any disagreement during the selection process was resolved with the help of other reviewers. The included articles were reviewed in full text and data extraction covered the following: title, author(s), year of publication, country, setting, methodology, and results. The extracted data were entered into the Excel sheet, and all the authors reviewed the information. The study details are charted in Table 1(extended data). Three independent authors participated in selecting the studies, and all authors reached a consensus on the studies to be included after discussion. Figure 1 shows the selection of studies in this review.

Figure 1. PRISMA chart.

Results

The study yielded 30,194 articles out of which 20,733 articles were screened for title and abstract screening after duplicate removal. After title and abstract screening, 194 articles were eligible for the full text screening, 183 articles were excluded as they did not meet the inclusion criteria, and finally 11 articles were included in the review. In total two studies were pilot interventional study, one randomized controlled study, one case-control, one retrospective study, three were cross sectional, one was cross sectional longitudinal study and two were qualitative in nature. Out of 11 studies, four were conducted in England (Dean et al., 2014; Ngamaba et al., 2021; Shimitras et al., 2003; Cella et al., 2016), three in USA (Iwasaki et al., 2014; Snethen et al. 2012; McCormick et al., 2012), two in Australia (Caddy et al., 2011; Hayes & Halford, 1996), one in France (Voruganti et al., 2006), and one in Israel (Lipskaya-Velikovsky et al., 2020). Further, these studies can be broadly classified into exploratory/observational and interventional studies, many of them being exploratory/observational. The results of these studies are explained below.

Discussion

The available literature shows that individuals with schizophrenia spend relatively little time engaging in leisure activities and that those activities are predominantly passive, reflecting a broader issue of reduced social participation and activity engagement within this population. People with schizophrenia often gravitate towards passive leisure activities, such as watching TV, relaxing, or sleeping, rather than engaging in more active or socially engaging pursuits (Hayes & Halford, 1996; Shimitras et al., 2003; Cella et al., 2016). This could be due to several factors intrinsic to the disorder, including negative symptoms like anhedonia, avolition, and social withdrawal, which reduce motivation and pleasure in daily activities (Harris & Horan, 2021). Further, there is a significant difference in time use between individuals with schizophrenia and the general population, with the former group spending considerably less time in active leisure activities (Cella et al., 2016). This difference emphasizes the impact of schizophrenia on social engagement and the potential isolation that comes from reduced participation in meaningful activities. The underutilization of active leisure activities highlights the need for targeted interventions that address the barriers to engagement faced by individuals with schizophrenia.

Also, the studies reveal that engaging in leisure activities offers significant benefits for patients with schizophrenia across multiple dimensions, including cognitive, clinical, functional, and quality of life aspects.

Cognitive benefits:

Leisure activities have been shown to positively impact cognitive functions, which are often impaired in individuals with schizophrenia.. Studies such as those by Lipskaya-Velikovsky et al. (2020) and Snethen et al. (2012) found that participation in structured leisure activities led to improvements in various cognitive domains such as executive functioning, language understanding, and visual memory.

Clinical benefits:

Leisure activities have been associated with reductions in both positive and negative symptoms of schizophrenia. Studies reported that engagement in leisure activities can reduce psychiatric symptoms such as anxiety, depression, and negative affect (Iwasaki et al., 2014; McCormick et al., 2012).

Functional benefits:

Engagement in leisure activities provides a structured way for patients to interact with their environment, develop coping strategies, and enhance their ability to manage daily tasks. Studies by Dean et al. (2014) and Snethen et al. (2012) demonstrated that leisure-based interventions could lead to increased community involvement, better planning abilities, and improved coping skills.

Quality of life benefits:

Leisure activities provide meaningful engagement that can enhance the sense of identity, autonomy, and belonging, all of which are essential for improving quality of life. Ngamaba et al. (2021) highlighted that individuals who engaged more frequently in leisure activities reported higher quality of life scores, particularly in domains related to social relationships, physical health, and psychological well-being.

Caddy et al. (2011) and Lipskaya-Velikovsky et al. (2020) both used a pre-post group intervention design. The former had a larger sample size (n=403 patients) compared to the latter (n=33 patients). (Caddy et al. 2011) focused on art- and craft-based creative therapies, whereas Lipskaya-Velikovsky et al. (2020) focused on the “Occupational Connections” intervention, which emphasized meaningful daily activities. Both studies reported improvements in mental health outcomes, but Caddy et al. (2011) demonstrated statistically significant improvements across various psychometric measures, while Lipskaya-Velikovsky et al. (2020) noted significant improvements in participation diversity and cognitive functioning. The larger sample size in Caddy et al. (2011) study may offer more robust statistical power, leading to a broader generalization of results. Lipskaya-Velikovsky et al. (2020) focus on personal meaningful activities aligns with recovery-oriented care, suggesting that interventions tailored to personal relevance may enhance recovery outcomes (Jacob, 2015).

Dean et al. (2014) employed a randomized controlled trial, Voruganti et al. (2006) used a case-control pre-post design and Snethen et al. (2012) employed a pilot intervention study. Dean et al. (2014) utilized an RCT, providing a high level of evidence but might have been limited by the nature of the intervention. Voruganti et al. (2006) employed a case-control design with a focus on physical and adventurous activities, which was likely more effective in promoting changes in self-esteem and global functioning, similar findings were noted in a study by (Mahindru et al., 2023). Snethen et al. (2012) study, although small, highlighted the importance of personalized interventions. Dean et al. (2014) had the largest sample, which typically increases the robustness of findings. Voruganti et al. (2006) and Snethen et al. (2012) had smaller samples, but the nature of their interventions might have led to more impactful outcomes despite this limitation. The type of intervention appears to be a critical factor in the outcomes. In Voruganti et al. (2006) physically demanding and immersive activities seemed to create more substantial changes compared to the more passive activities in (Dean et al., 2014) and the community-focused intervention in Snethen et al. (2012). The differences in outcomes can be attributed to the intensity, physicality, and immersive nature of the interventions. Voruganti et al. (2006) achieved significant improvements in global functioning and self-esteem, likely due to the challenging nature of the activities. Snethen et al. (2012) showed improvements in community involvement, highlighting the value of individualized and participant-centered approaches. Dean et al. (2014) lack of significant differences might suggest that the intervention’s intensity or the types of activities were insufficient to produce substantial changes in global functioning.

The types of leisure activities varied across studies, reflecting differences in cultural factors, feasibility, acceptability, and affordability. This variability suggests that leisure-based interventions should be tailored to individual preferences and contexts. The duration of leisure-based intervention sessions ranged from 45 minutes to 1 hour. The variability in session length may be attributed to the client-centered nature of these interventions.

Hayes & Halford (1996) and Shimitras et al. (2003) employed observational designs, making them suitable for examining time use patterns among individuals with schizophrenia. However, while Hayes and Halford (1996) focused specifically on the impact of employment status, Shimitras et al. (2003) provided a broader overview of daily activities within a larger population. Shimitras et al. (2003) had a significantly larger sample size (n=229 participants) compared to (Hayes & Halford, 1996) (n=48). Though Shimitras et al. (2003) study has a larger sample size, (Hayes & Halford, 1996) study may offer deeper insights into the specific subgroup of employed versus unemployed individuals with schizophrenia. The outcomes of the two studies are complementary. Hayes and Halford (1996) found that employment supports greater diversity in activities, including leisure, which contributes to overall well-being. On the other hand, Shimitras et al. (2003) identified a general lack of engagement in meaningful activities among individuals with schizophrenia, particularly those who may not be employed. Together, these findings suggest that promoting employment and creating opportunities for structured, active engagement could be key strategies for improving the quality of life for individuals with schizophrenia.

Iwasaki et al. (2014) used in-depth interviews, which allowed for a comprehensive understanding of leisure’s role in recovery but may have limited generalizability due to subjective reporting. McCormick et al. (2012) used the experience sampling method, providing real-time data on activities and emotions, which may offer more objective insights but with a smaller sample size. Iwasaki et al. (2014) had a larger sample (n=101), allowing for a broader understanding of leisure’s impact across not only schizophrenia, but other major mental disorders. It also highlighted the broad benefits of leisure activities, including improved recovery outcomes and cultural considerations, reflecting the importance of integrating leisure into treatment plans. McCormick et al. (2012) specifically linked physically active leisure activities to fewer negative emotional experiences, providing more targeted recommendations for improving subjective well-being in SSD patients. Both studies emphasize the importance of activity in mental health but with different approaches, and with varying depths of analysis.

Cella et al. (2016) is the only study that we came across, that compared people with schizophrenia to the general population, revealing that those with schizophrenia spent less time in meaningful activities, similar findings were also observed in (Minato & Zemke, 2004; Ohi et al., 2019; Strassnig et al., 2019). This highlights the impact of schizophrenia on daily life and suggests the need for targeted interventions to increase engagement in meaningful activities. Thus, overall the results of the existing exploratory as well as interventional studies infer that leisure-based interventions have a beneficial role in patients with schizophrenia.

Conclusion

The purpose of this scoping review was to gather and describe the available research on the use of leisure as an intervention among individuals with schizophrenia. have proven beneficial for individuals with schizophrenia, positively impacting clinical, cognitive, functional, and quality of life domains. These interventions improve symptoms, cognitive functions, daily functioning, and overall well-being. The evidence supports incorporating leisure-based activities into therapeutic programs, highlighting their value as a key component of comprehensive care. Sustained employment is a facilitator for active leisure. Flexible, client-centered, and culturally appropriate interventions can help overcome the challenges of passive lifestyles and encourage more active participation in meaningful leisure activities. Future research, especially the interventional studies, should continue to validate leisure based interventions, to optimize treatment strategies for schizophrenia.

Data availability

No data associated with this article