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

Research question

What are the available studies on leisure-based interventions or programs provided for adults with schizophrenia?

Search strategy

Having specific criteria for searching the relevant articles is a requirement to answer the question framed for any scoping review (Arksey & O’Malley, 2005). The databases Scopus, PubMed, and Embase were accessed. The grey literature searches through Google scholar were carried out.

Search keywords

“Schizophrenia” AND “Psychosis” AND “leisure” OR “leisure activity” OR “leisure activities” OR “recreation” OR “activity” OR “activity group” OR “activity groups” OR “creative activity” OR “recreational therapy” OR “leisure-based intervention” AND “Adults” OR “Adult”. The Boolean search strategy was applied to connect using AND, and OR.

The following criteria were decided on for the scoping review by all the reviewers:

Inclusion criteria

Exclusion criteria

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.

Leisure activities used as an intervention

Two pilot interventional studies used recreational activities, cooking group as part of the intervention and duration lasted for average of one hour (Lipskaya-Velikovsky et al., 2020; Snethen et al. 2012). A Randomized control design study used activity group which included activities like discussions, board games and visits to places of interest (Dean et al., 2014), a case control study used camping, kayaking, rock climbing, high and low ropes courses, and a picnic in their summer module and the winter module included skating, snow shoeing, skiing, snowboarding, ice fishing, indoor rock climbing, and bowling (Voruganti et al., 2006). A retrospective study investigated on art and craft-based activities like painting, beading, sewing, clay work, paper craft and were used to participants of the group and its outcome in individuals with schizophrenia (Caddy et al., 2011).

Leisure activities and association with various factors in individuals with schizophrenia

McCormick et al. (2012) study found that majority of leisure activity perform by people with schizophrenia were sedentary (31%) and sedentary non-leisure (25.7%) and physically active leisure was significantly associated with lower negative emotion. The findings from (Iwasaki et al., 2014) emphasize the importance of meanings that persons with mental illness including schizophrenia gain from leisure are connection/belonging, identity, freedom/autonomy and to reduce perceptions of boredom. Also, a greater perception of being actively engaged was a significant predictor of recovery and overall physical and mental health and less frequent psychiatric symptoms. Furthermore, the use of leisure both for coping with stress and reducing boredom significantly predicted fewer psychiatric symptoms. People with psychosis who attend more leisure activities have a higher quality of life. Quality of life score was higher amongst males who attended leisure activities (Ngamaba et al., 2021).

Time use and schizophrenia

Time use studies among schizophrenia found that, people with schizophrenia spent most of their time in passive leisure such as reading, watching TV or videos, relaxing, and sleeping and less time in active lifestyle (Hayes & Halford, 1996; Shimitras et al., 2003; Cella et al., 2016).

Facilitators and barriers to participate in leisure activities

The authors of the reviewed articles have reported of facilitators such as leisure-based intervention being flexible (Lipskaya-Velikovsky et al., 2020), client centered, and interest based (Snethen et al., 2012), feasible, available, acceptable, and cost-effective (Voruganti et al., 2006). Barriers in implementing leisure-based interventions were the characteristic passive lifestyle of patients with schizophrenia, chronic illness, negative symptoms, cognitive deficits, time use and recreational skills deficits that evolve over time (Hayes & Halford, 1996; Shimitras et al., 2003; Cella et al., 2016).

Clinical and functional outcomes

A novel adventure- and recreation-based group intervention was found to be marginally better than standard clinical care in terms of perceived cognitive deficits and functioning, while significant improvements were observed in terms of global functioning and self-esteem, there was a strikingly significant weight loss (mean 12 lb) among study subjects over the course of the year (Voruganti et al., 2006). Studies using recreational activities as interventions found improvement in several elements of cognitive function including language understanding, executive functioning, functional capacity and visual memory, increased community involvement, developing coping skills, positive and negative schizophrenia symptoms (Lipskaya-Velikovsky et al., 2020; Snethen et al., 2012; Dean et al., 2014). A retrospective study found that use of creative activities in the inpatient setting has potential benefits for people experiencing mental health problem including reductions in self-reported psychological distress and clinician-rated symptoms and improvement in daily functioning (Caddy et al., 2011).

Strength and limitations

To the best of our knowledge, this is the first review on leisure-based interventions in individuals with schizophrenia. The limitation of our study is that only published literature in English was searched in the current review, which may have resulted in missing relevant studies. The reviewers have tried all possible ways to look for relevant articles, but individual biases of the authors may not be negated. The current review may help future researchers to conduct relevant research related to gaps identified in the current review. Most of the studies identified in the current scoping review have found that there is a positive effect of leisure-based interventions in treatment of schizophrenia, but there is the risk of bias that invites us to be cautious when interpreting these results.

Gaps identified and future implications

There are limited studies on leisure-based interventions among individuals with schizophrenia. Future studies may focus on evaluating the effectiveness of leisure-based interventions specifically on various occupations such as activities of daily living, instrumental activities of daily living, social participation, sleep and rest, other associated factors such as self-confidence, motivation, emotional expressions, and communication skills. Also, studies could be done in developing guidelines in terms of duration and the type of modalities that could be used for persons with schizophrenia. The studies could be done in low middle income and middle-income countries using different study designs to determine the best means of conducting research on this topic. The study also highlights a need of conducting randomized controlled trials and mixed method studies to understand the effectiveness of leisure-based interventions in schizophrenia.