Several studies about psychosis, quality of life and leisure or social activities have been published internationally, which seem very relevant to this study. For example, Pondé et al. (2009) evaluate the role of leisure in the life of patients living with psychosis. Vancampfort et al. (2011) argue that less physical leisure activity decreases quality of life. Arraras et al. (2018) discuss determinants of quality of life in Spanish outpatients with schizophrenia spectrum disorders. Other studies (Alonso et al. (2009); Brissos et al. (2011); Karow et al. (2005); Meneghelli et al. (1999)) examine the importance of quality of life for people who have psychotic disorders, showing that social relations and leisure activities play a strong role in increasing or supporting quality of life. Therefore, the topic of the study reviewed here is not entirely new. However, its method of cross-sectional analysis and a target group of participants in England could add a new nuance to the field.

This study considers the impact of participating in leisure activities on quality of life, specifically for people who have psychosis based in England. Leisure is loosely defined by the authors as “any un-obligated time or activity that brings direct satisfaction, a state of being content and happy following participation in specific activities performed in your own spare time without any pressure for survival.”

Ngamaba and colleagues (2023) proceed with the intention to fill two evidence gaps in this study about leisure activities and quality of life for people with psychosis in England. They claim that “little is currently known about the participation in leisure activities of people with psychosis”. Furthermore, there are no existing multi-site cross-sectional studies that examine leisure activities and quality of life in people with psychosis. This theme has not been explored specifically in previous Mental Elf blogs, although Potter (2021) usefully examines leisure activities and health outcomes, and Morgan (2015) intersects leisure with people who have learning disabilities in the context of daily life activity.

Methods

The authors conducted a cross-sectional survey, working with patients who are cared for under Community Mental Health Teams in 6 NHS mental health trusts across England. The authors recruited 533 participants who were adults aged 18–65 and who specifically had the diagnosis of a psychosis-related condition. This condition is defined using the International Classification of Diseases, Tenth Revision (ICD-10, published in 2019). All participants had a diagnosis between F20-29 on this register, indicating schizophrenia, schizotypal and delusional disorders.

The study examined relationships between participating in leisure activities and quality of life, including the mediating factor of social contacts (which may increase or decrease the effects of participating in leisure activities), by engaging with four different measures to support data collection and analysis: the Time Use Survey, the Social contacts assessment, the Manchester Short Assessment of Quality of Life and A Structural Equation Model. These measures were also used to define and assess quality of life, the main question in the study. Leisure activities, social contact and satisfaction were measured over a period of 7 days.

Results

Looking at the sample, most participants were male, single, middle-aged, white, and diagnosed with schizophrenia (n=81, 15.8%).

The study showed that participants participated in an average of 2.42 leisure activities during the 7-day period of measurement. The average quality of life score was measured as 4.97 (scale 1-7). The more leisure activities participants engaged with, the more their quality of life increased. Another finding showed that engaging in leisure activities entailed having more social contacts, although having social contacts and the quality of life did not play a significant role in improving quality of life.

We see that participants who were female or unemployed had a decrease in quality of life. Results show that males seem to benefit more than females from participating in leisure activities.

Statistical analysis examined the relation between leisure activities, social contacts, and quality of life, in relation to socio-demographic factors and their diagnosis. Many different factors influence quality of life (and each other) as can be seen in Figure 1 included in the original paper.

Conclusions

The authors concluded:

People with psychosis who attend more leisure activities have a higher quality of life.

The conclusion may seem obvious, or self-evident; perhaps this point is not argued strongly enough. Results show that quality of life differed according to gender and employment status, but this gender difference is stated, not explained.

The authors said that more research is required to increase attendance, for more participants with psychosis to do more leisure activities (and feel the benefits).

Work done by Fancourt et al. (2021) crafts a “multi-level theoretical framework of mechanisms of action”, which goes far to examine how leisure activities affect health (and quality of life, which follows). Ngamaba et al.’s paper, here reviewed, would do well to consider how this model works in relation to people with psychosis (which Fancourt et al. do not specifically examine).

Strengths and limitations

This is a positive study because it suggests that engaging in leisure may help and support people who have psychosis, specifically in England. Although this is unquestionably a strength, the study has limitations, some of which the authors state. It was a cross-sectional study, so it is not possible to infer causality between variables – it is not clear what exactly is causing the increase in quality of life for people with psychosis, many other factors are apparent, beyond participating in leisure, which are not measured. Longitudinal or intervention approaches could be used to assess the changes more accurately.

The study only takes data across a seven-day period (without a before/after comparison). This poses limitations since it does not gauge a baseline reading and does not assess the difference or change in the quality of life following engagement in leisure. Furthermore, as the authors state, participants who have a higher quality of life might be more motivated to participate in leisure activities, from the start – colouring results. The effects of participating in leisure on the specific symptoms or effects of psychosis are not examined. We don’t learn how or why leisure affects psychosis, per se.

The method of cross-sectional analysis and target group of participants based in England could add nuance to the field of research that already exists. But there is no consideration about what it is like to be specifically English, or participate in leisure activities in England, or being diagnosed with psychosis in England, if this is to be the focus.

The study concludes with the proposition it began with (participation in leisure activities improves quality of life). The niche of referring to participants who specifically have psychosis, specifically in England, is not sufficiently quantified.

Implications for practice

The findings of this study support more people who have psychosis to engage in leisure activities, which this research suggests is linked to greater quality of life, which can only be a good thing. During my historical experience of psychosis, engaging in any activity was extremely difficult because I was very distracted by my illness. However, when I was able to start writing, painting, or going on a nature walk, these leisure activities certainly helped me a great deal. For this reason, the central hypothesis of this study holds fast and must be shouted from the rooftops, until more people with psychosis (and everyone) can enjoy un-obligated time to simply be creative. The imagination breaks down barriers because when we imagine something, there are no limits, we can be or do anything. Being creative does not require talent or agency; it is something we can all access when we dare to try, and when we have the space to be open. Facilitating this open space for un-obligated time and providing the opportunity for people to imagine a different world or a world of difference, will undoubtedly improve their quality of life.

Mental health practitioners supporting people with psychosis need to also be aware of the evidence and encourage community engagement. Often, it’s hard for people to find the motivation to initiate an activity, find local groups, or link with other community members who share similar interests. Social prescribing and signposting to appropriate organisations can be helpful alongside other therapeutic interventions. Mental health practitioners can work with patients to break down activities into smaller, achievable tasks, so they are easier to plan and carry out. Communication is essential. For example, mental health practitioners can support people with psychosis to do one specific leisure activity a week and maximise the benefits, by taking into account patients’ access needs and being available to debrief and review how it has gone. As I found during my own recovery from psychosis, when patients try out and enjoy new activities, they develop skills, confidence, and autonomy. This provides a distraction and then a proactive, healthy way of living.

Statement of interests

LC has lived experience of psychosis and is an artist. She has no involvement with the current study.

Links

Primary paper

Ngamaba, K.H., Webber, M., Xanthopoulou, P. et al. (2023) Participation in leisure activities and quality of life of people with psychosis in England: a multi-site cross-sectional study. Ann Gen Psychiatry 22: 8, doi:  10.1186/s12991-023-00438-1

Other references

Morgan, H. (2015) ‘More time for what’? Leisure, life and learning disabilities

Potter, A. (2021), Mapping the links between leisure activities and health outcomes: the Multilevel Leisure Mechanism Framework

Arraras, J.I., Ibañez N., Basterra, I.  Pereda, N., Martin, M., Iribarren, S. (2018) Determinants of Quality of Life in Spanish outpatients with schizophrenia spectrum disorders. Eur J Psychiatry, 32;113-21, doi: 10.1016/j.ejpsy.2017.11.001

Brissos S., Dias V.V., Balanzá-Martinez V., Carita A.I., Figueira M.L. (2009) Symptomatic remission in schizophrenia patients: relationship with social functioning, quality of life, and neurocognitive performance. Schizophr Res. 129; 133-6, doi: 10.1016/j.schres.2011.04.001

Fancourt, D., Aughterson, H., Finn, S., Walker, E., & Steptoe, A. (2021). How leisure activities affect health: a narrative review and multi-level theoretical framework of mechanisms of action. The Lancet. Psychiatry, 8(4), 329–339. https://doi.org/10.1016/S2215-0366(20)30384-9

Karow A., Moritz S., Lambert M., Schoder S., Krausz M. (2005) PANSS syndromes and quality of life in schizophrenia. Psychopathology 38;320-6, doi: 10.1159/000088921

Meneghelli, A., Masaraki, S., & Patelli, V. (1999) Quality of Life in the Rehabilitation of Psychotic Patients. International Journal of Mental Health, 28:3; 68-76. https://www.jstor.org/stable/41344904

Pondé M.P., Peireira C.T.M., Leal B., Oliveira S.C. (2009) The Role of Leisure in the Lives of Psychotic Patients: A Qualitative Study. Transcultural Psychiatry, 46:2; 328-339. doi:10.1177/1363461509105822

Vancampfort, D., Probst, M., Scheewe, T., Maurissen, K., Sweers, K., Knapen, J. de Her, M. (2011) ‘Lack of physical activity during leisure time contributes to an impaired health related quality of life in patients with schizophrenia’,  Schizophrenia Research, 129; 2–3, 122-127, doi: 10.1016/j.schres.2011.03.018

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