Influence of family life on the course of schizophrenic disorders: a replication

High level of expressed emotions in the family of people with schizophrenia: has a covert abrasive behaviours component been overlooked?

BACKGROUND

High expressed emotion (EE) in a patient's family is a known risk factor of relapse in schizophrenia. The three components of high EE - criticism, hostility and emotional over-involvement - were developed through a data-driven approach and a focus on overt abrasive behaviours. The influence of covert abrasive behaviours has not been explored.

AIMS AND METHODS

This study aims to explore both overt and covert abrasive behaviours through semi-structured interviews conducted with 22 people with schizophrenia, who were recruited through iterative purposive sampling.

RESULTS

Thematic analysis suggests that participants' experiences of overt abrasive behaviours resonate with the three-factor structure of high EE, except "emotional over-involvement" is renamed to "over-involvement" to focus on behaviours and embrace different levels or types of emotional reactions. Regarding covert abrasive behaviours, two domains are proposed: disassociation and apathy, which focus on family members' disengaging actions and indifferent attitudes respectively. While both overt and covert abrasive behaviours cause psychological distresses and behavioural reactions on the participants, their precise impacts are not entirely the same.

CONCLUSION

People with schizophrenia experience both overt and covert abrasive behaviours with family members. The findings of this study may expand the conceptualization of high EE, enhance its content validity, and provide an extended conceptual framework for developing more comprehensive measures.

Caregiver expressed emotion as mediator of the relationship between neuropsychiatric symptoms of dementia patients and caregiver mental health in Hong Kong

Objectives: Quality of life among Hong Kong's family dementia caregivers is a current heightened public health concern. This was one of the first East Asian studies to examine the role of family expressed emotion (EE) in the negative caregiver outcomes associated with dementia caregiving. EE comprises overinvolved and critical communications in families of people with mental illness. In this research, caregiver EE was evaluated as a mediator of the relationship between behavioral and psychological problems associated with dementia (BPSD) and negative caregiver outcomes.Method: Participants were 89 Hong Kong family caregivers (79% female, 84% married, 43% >50 years of age) of people with diagnosed dementia, recruited from elder day care centers. Caregivers completed the Neuropsychiatric Inventory (NPI), Cohen Mansfield Agitation Inventory (CMAI), Level of Expressed Emotion scale (LEE), Zarit Burden Interview, and Center for Epidemiological Studies Depression Scale (CES-D).Results: Agitation, delusions, hallucinations, aggression and irritability were BPSD most associated with caregiver burden and depression. EE significantly mediated the BPSD-negative caregiver outcome relationship. Among EE subscales, intrusiveness was significantly more common and less associated with negative caregiver outcomes. Caregiving hours, low family support, and religious nonaffiliation were associated with EE and poorer caregiver outcomes.Conclusions: The negative impact of BPSD on dementia caregivers in Hong Kong is influenced by EE. Higher scores on EE intrusiveness may be partly accounted for by filial piety, a strong sense of family responsibility characterized by high attentiveness to elderly family members. As EE is a potentially modifiable factor, interventions are considered.

Factors associated with family functioning among people with a diagnosis of schizophrenia and primary family caregivers

WHAT IS KNOWN ON THE SUBJECT?: Families act not only as the primary support for people with a diagnosis of schizophrenia but also as partners in the healthcare system. Families who have members with mental disorders, particularly schizophrenia, experience challenges in family functioning. Research on families in relation to schizophrenia primarily focuses on the determinants that affect family functioning from primary family caregivers' perspectives. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: This report provides evidence that there is a concordance between family functioning and inpatient psychiatric rehabilitation facilities for the patient-caregiver dyad; both care-receivers and primary family caregivers considered family functioning as poor. Care-receivers with lower education levels, increased number of previous hospitalizations and poor quality of family-centred care experienced unhealthy family functioning. Primary family caregivers and care-receivers with higher education levels, lower suicidality and greater quality of family-centred care experienced healthier family functioning. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Understanding the degree of family functioning, particularly its concordance and correlates as perceived by patients and primary family caregivers, may serve as a platform for inculcating assessment of family functioning to achieve holistic patient care. Open dialogue in family-focused care planning is essential to facilitate collaborative partnerships and improve family functioning among people with a diagnosis of schizophrenia and their primary family caregivers. Further research on culturally relevant, evidence-based family interventions to enhance the functioning of affected families is warranted, especially for families with members in inpatient psychiatric rehabilitation facilities. ABSTRACT: Introduction Families provide frontline caregiving support for people with a diagnosis of schizophrenia. However, research primarily addresses correlates of family functioning from primary family caregivers' perspectives. Aim To examine perceived family functioning, particularly its concordance within patient-caregiver dyads and associated factors in families of people living with schizophrenia. Methods A cross-sectional, descriptive correlational design was used. A total of 133 dyads of patients and primary family caregivers from inpatient psychiatric rehabilitation services participated. Descriptive statistics, independent-sample t test, one-way ANOVA, Pearson's correlation coefficients, intraclass correlation coefficient and stepwise multiple linear regression analyses were applied. Results Family functioning was perceived as impaired by patient-caregiver dyads, and there existed a concordance in this regard. Patients' and family caregivers' education levels, patients' suicidality, number of previous hospitalizations and quality of family-centred care correlated with patients' and primary family caregivers' family functioning. Discussion Findings highlight the importance of patient- and family-reported family functioning with implications to address individual and collective concerns. Implications for Practice Evidence-based family interventions are crucial for assisting vulnerable families in promoting family functioning. Mental health nurses should facilitate collaboration and open dialogue concerning perspectives of patients and families to improve delivery of comprehensive mental health care.

Family Relationships and Alzheimer's Disease: A Systematic Review

BACKGROUND

Family caregivers of people with Alzheimer's disease are the most important support in concrete personal and economic terms. Family dynamics play a fundamental role in the provision of informal caregiving benefits.

OBJECTIVE

This review aims to identify factors related to the family caregiving of relatives with Alzheimer's disease, taking specifically into account the construct of coping and expressed emotion.

METHODS

This is a systematic review including articles selected using search terms including "caregivers," "Alzheimer's," "family," and "relationship" in research databases. Findings were synthesized and categorized into themes.

RESULTS

A total of 454 abstracts were identified. Following screening, lateral searches, and quality appraisal, 36 studies were included for synthesis. A total of 5 themes were identified: burden; demographics; coping strategies; caregiver mental health; and family dynamics and expressed emotions.

CONCLUSION

The quality and level of evidence supporting each theme varied. We need further research into family dynamics ameliorating the caregiving and how to measure it.

Predictors of criticism and emotional over-involvement in relatives of early psychosis patients

Mechanisms underlying the manifestation of relatives’ expressed emotion (EE) in the early stages of psychosis are still not properly understood. The present study aimed to examine whether relatives’ psychological distress and subjective appraisals of the illness predicted EE dimensions over-and-above patients’ poor clinical and functional status. Baseline patient-related variables and relatives attributes comprising criticism, emotional over-involvement (EOI), psychological distress, and illness attributions were assessed in 91 early psychosis patients and their respective relatives. Relatives were reassessed regarding EE dimensions at a 6-month follow-up. Relatives’ psychological distress and illness attributions predicted criticism and EOI over-and-above patients’ illness characteristics at both time points. Relatives’ increased levels of anxiety, attributions of blame toward the patients, an emotional negative representation about the disorder, and decreased levels of self-blame attributions predicted EE-criticism at baseline. Relatives’ anxiety and negative emotional representation of the disorder were the only significant predictors of EE-criticism at follow-up, whereas anxiety, attributions of control by the relative and an emotional negative representation about the disorder predicted EE-EOI both at baseline and follow-up assessments. Understanding the components that comprise and maintain EE attitudes should guide early psychosis caregivers in family interventions, enhancing proper management of psychological distress and reduction of negative appraisals about the illness. The prevention of high-EE attitudes over time in a sensitive period such as early psychosis might be critical in shaping the health of caregivers and the outcome of the affected relatives.

Expressed emotion in an 8 year follow-up

This study addresses the questions if and for which patients expressed emotion (EE) has a predictive validity in an 8 year follow-up study and if this is dependent on the residential form, especially on patients and relatives living together. Eight years after a baseline examination (Camberwell Family Interviews [CFI], global assessment scale [GAS], symptom score) 69 of 99 patients were reexamined. The number and duration of rehospitalizations as well as the symptom and GAS scores were recorded. These was no difference between outcome of high and low EE patients with a duration of illness of less than 4.5 years and for those living with partners. Patients from high EE parents with a longer duration of illness (> 4.5 years) at the outset of the study were significantly more often and longer in hospital. They had significantly higher symptom and GAS scores at the outset of the study and after 8 years. The EE effect was equal in the first and second 4 years of the follow-up and was independent from patients and parents living together. The results emphasize the significance of the EE index as a long-term predictor for the course of schizophrenic illness. The independence of the prediction from living together is an argument against a simple causal interpretation of the connection between EE and the course of schizophrenia.

Emotional family atmosphere and relapse: investigations on the role of relapse definition, duration of illness and resignation of relatives

An analysis of existing studies on the expressed emotion (EE) concept shows that the predictive validity of the EE index depends on the definition of relapse. Whilst symptomatic relapses are recorded in patients from high-EE families, about 3 times as often as in patients from low-EE families, a comparison of hospitalization rates reveals a difference of only approximately 1.5 times. In the Münster Families Study, a prospective intervention study to evaluate the therapeutic impact of relatives' groups, the predictive value of the familial emotional atmosphere could be measured in a prospective design. Ninety-nine DSMIII Schizophrenics, 72 male, 27 female, mean age 27 (SD 6.6), mean duration of illness 5.5 (SD 4.3) were followed up. In the first eighteen months patients from high-EE- families had a risk of rehospitalisation approximately 1.5 (p < 0.05). Further analysis showed that relapse rates among patients from high-EE and low-EE families were roughly the same for patients with a duration of illness of less than 4.5 years but were significantly different after a longer duration (p = 0.019). Besides a high EE rating, resignation of relatives was also a significant (p = 0.000) predictor of rehospitalisation for high and — even more — low EE families. Possible causes of these findings and therapeutic consequences are discussed.

Schizophrenia and family rituals: measuring family rituals among schizophrenics and “normals”

Family rituals consisting of ceremonial acts, traditions and patterned interactions serve as a basis of communication, collective identity, and stabilizing relationships. Therefore, the measurement of rituals in a schizophrenic family is an objectification of the family's symbolic communication and integration. Based upon this, the relationship between family rituals practice in 138 families both with a schizophrenic member (71) and without (67) was examined by the use of an originally developed instrument, the “Family Rituals Scale” (FRS). The psychometric properties of this instrument were tested and proved to be reliable. Families with a schizophrenic member were less ritualizing than the “normal” families. The correlation between FRS scores and Global Assessment Scale scores in schizophrenic patients was negative (the higher the psychosocial functioning level, the lower FRS scores), which means a higher performance of family rituals. The effect of other factors on FRS scores and the therapeutic implications are discussed.

Expressed emotion in the therapeutic relationship with schizophrenic patients

Patterns of interaction and attitudes in the relationships of 21 young schizophrenic patients, their parents and therapists were explored and compared with each other in this pilot study. The focus was on expressed emotion (EE), which was revealed to have an important impact on the course of the illness. In this study, the EE status of the relatives as well as of the therapists was rated using the five-minute speech sample method. Furthermore, data on the quality of interaction of therapists and parents with the patients were derived from the therapist/relative-patient interaction scale. Results showed that one-third of both the therapists and the parents were rated high on EE. High-EE relatives were rejected and perceived as inscrutable by the patients. The assessment of the therapeutic and familial relationships demonstrated the patients’ need for unequivocal communication. Differences and similarities in the interaction styles, and their implications for research and therapy are discussed.

Long-term studies of antipsychotic drugs in schizophrenia

Studies on long-term efficacy and safety should be a main concern in the evaluation of novel antipsychotics. The present paper is a review of important issues related to the design and performance of such trials. The variability of the natural course of schizophrenia, the variability in treatment response, and the variability of actions of different neuroleptics need to be considered. Long-term studies need to address maintenance of efficacy, prevention of relapse and recurrence, health economics, quality of life and a large number of safety issues in order to get approval for new drug applications and reimbursement on expensive new medicines. Assessment instruments for efficacy, tolerability and safety, need to be supplemented with rating scales for various aspects of psychopathology (positive, negative, deficit symptoms), social and work functioning, drug induced mental side effects, quality of life and accounts of total treatment costs.

[Integrating close relatives of people experiencing schizophrenia in the mental health system]

OBJECTIVES

Schizophrenia is a long-term, stigmatized disease which often leads to social impairment, unemployment and isolation, with heavy negative social and psychological consequences both on patients and their families. Close relatives' perceptions of the illness have an impact on their mood, and then on the course of the patient's disease itself. In this context, our objective is to evaluate the perceptions of French close relatives of people with schizophrenia or schizophrenia spectrum disorders, about the disease itself, as well as their experience within the mental healthcare system.

METHODS

Our population is constituted of close relatives of people experiencing schizophrenia or schizophrenia spectrum disorders, recruited through an active patient and families association. We used a French translation of a standardized questionnaire, the Brief Illness Perception Questionnaire, as well as an extensive semi-structured interview assessing the experience of the mental healthcare system (diagnosis divulgation, information about disease and treatment, family psychoeducation, hospitalization experience, and access to health professionals). Some questions in the last were open-ended questions, which allowed us to gather detailed and personal responses, in order to be able to illustrate our quantitative findings with brief clinical cases.

RESULTS

Among the 27 close relatives included in our research, results to the standardized questionnaires show threatening perceptions of the disease, in particular regarding the probable duration of the disease and the frequency of symptoms. In our study, a better access to diagnosis is associated with a shorter perceived probable duration of the disease, while an easier communication with healthcare professionals (in particular nurses) is associated with the perception of a better efficiency of the treatment. Family psychoeducation seems to be associated with the perception of less frequent symptoms. When the patient lives independently or is older, close relatives of our sample perceive a higher risk of chronicity of the disease. Our results tend to confirm the available literature on the subject of information towards families in psychiatric services: indeed, studies, especially in the field of nursing research, have shown that families tend to feel excluded from care processes and from useful information exchanges about the patient's illness. Our study also confirms the fact that family psychoeducation seems to reduce the frequency of present symptoms in the patient as perceived by the close relative. This effect could be caused by a better understanding of the real symptoms or by an enhancement of the family mood and functioning. Even if the patient's hospitalization was a difficult or very difficult experience for close relatives, it showed no relationship with their illness negative perceptions. Sociodemographic variables of the patient, such as age or the fact of living in an independent household, were associated in our research with the close relatives' view of a higher potential chronicity of the illness; this could be explained by a different stage of acceptation of the illness when compared to close relatives taking care of a younger or still dependent patient.

CONCLUSIONS

Our results plead for further research on a larger and less homogeneous sample. Confirming our findings could help build useful recommendations leading to better integrated families who currently seem to feel relatively isolated and exclused in the healthcare process, despite the strategic role they could play and despite the many recommendations of public health policies in that matter. Efforts should continue to be made to reach the goal of a better inclusion of families and close relatives of people experiencing schizophrenia or schizophrenia spectrum disorders, in particular in the field of information and communication with health professionals, both areas which seem to have a potential effect on close relatives' illness negative perceptions. Family psychoeducation deserves more attention and should be more systematically proposed to French families with an easier and free access.

The effect of maternal depression on mental representations and child negative affect

BACKGROUND

Maternal depression is a widely recognized public health concern with significant implications for child functioning, including the development of negative child affect and risk for later depression. Negative mental representations may partially account for the association between maternal depression and child negative affect.

METHODS

The effect of depression on low-income mothers' representations of their child, self, and mother was assessed via Expressed Emotion (EE) during Five-Minute Speech Samples. Direct and indirect pathways between maternal depression, EE, and child negative affect were examined. Mothers (M = 24 years old) who had experienced a major depressive episode (n = 144) since child's birth, non-depressed comparison mothers (n = 62), and their children participated.

RESULTS

Examination of between-group differences revealed that depressed mothers had higher levels of overall self EE. Trend results also suggest depressed mothers may have higher overall EE toward their children and their own mothers. Novel coding systems for EE toward self (Identity and Depressotypic Cognitions) and EE toward mother (Source of Concrete Support and Resolution of Past Adversity) were also developed and tested. A significant indirect relation was found between maternal baseline depression and child negative affect at 26 months via the mother's level of EE-Criticism of her mother.

LIMITATIONS

Certain EE subcodes may need to be adapted for young children and high-risk, low-income participants.

CONCLUSIONS

Findings highlights the importance of relational interventions that focus on maternal representations for women with depression and their children.

Introduction to the Special Issue: Mechanisms of Action in Cognitive-Behavior Therapy

Research into mechanisms of treatment outcome in cognitive-behavior therapy (CBT), as work evaluating potential mechanisms through mediator and moderator analyses, has been increasing. In recognition of this growth in more refined analyses of functional components of treatment, this special issue highlights a diverse range of research-evaluating mechanisms, as well as mediators and moderators, of outcome. It is anticipated that the research described in these articles will stimulate additional investigations as well as provide important insights for clinicians in refining treatment programs.

No correlation among expressed emotion, anxiety, stress and weight loss in patients with overweight and obesity

Background

The onset of some types of obesity may correlate with specific familial relational patterns, and expressed emotion (EE), the family life's 'emotional temperature', may play a role in obesity treatment compliance and outcome.

Objective

The aim of this study is to address the current gap in the literature about EE and obesity, assessing EE in a sample of patients with overweight or obesity and their relatives. A further objective is to assess patients' weight loss, patients' and relatives' anxiety, perceived stress and their possible correlation with EE and diet compliance.

Design

A total of 220 patients with overweight or obesity and 126 relatives were recruited; their socio-demographic and clinical features were collected; and Level of Expressed Emotion Scale (LEE), State-Trait Anxiety Inventory 1 and 2 (STAI-Y1 and STAI-Y2) and Paykel Scale of Stressful Life Events were administered.

Results

Patients' baseline body mass index (BMI) was negatively correlated with educational level, but we failed to find any correlation between BMI and the other variables assessed. We found a positive correlation between EE median and stressful life events, as well as between median EE and state and trait anxiety.

Conclusions

Our results seem to suggest that other factors than the psychological ones we investigated may play a role in treatment adherence and outcome in patients with overweight and obesity.

Usability evaluation of an eHealth intervention for family carers of individuals affected by psychosis: A mixed-method study

Background

Existing research suggests that eHealth interventions targeting family carers of individuals with long-term illness offer a promising approach to care delivery. In particular, digital psychoeducational interventions with interactive psychosocial support are well-received with high rates of satisfaction and acceptability. However, development of such interventions for psychosis carers is lacking. We developed a multi-component eHealth intervention specifically for carers of individuals affected by psychosis, called COPe-support (Carers fOr People with Psychosis e-support).

Objective

Using mixed methods to evaluate usability, system heuristics and perceived acceptability, we conducted a usability study to establish the suitability of the intervention prototype for the target user group.

Methods

Twenty-three carers were recruited to the study and participated in a think-aloud test or a remote online trial of the intervention. Qualitative feedback, post-use System Usability Scale (SUS) scores, and real-world usage data collected from the tests were analysed. These were also supplemented with heuristic evaluation data provided by an independent eLearning technology expert.

Results

Participants evaluated the intervention content as useful and helpful, and indicated that the system had satisfactory usability with a mean SUS score of 73%, above the usability quality benchmark threshold. Study results identified some minor usability issues, which were corroborated with the eLearning expert’s heuristic evaluation findings. We used these results to refine the COPe-support intervention.

Conclusions

The usability study with end-users and service providers identified real-life usage and usability issues. The study results helped us refine COPe-support and its delivery strategy before its launch as part of a large-scale clinical trial.

Parental criticism and behavior problems in children with autism spectrum disorder

Associations between parent critical attitudes (a component of the Expressed Emotion construct) and behavior problems have been relatively well established in adolescents and young adults with autism spectrum disorder, but use of systems adapted for children with autism spectrum disorder and additional investigations with younger samples are needed. This study examined parental criticism, derived from a population-specific coding system, as related to behavior problems in children with autism spectrum disorder between the ages of 4 and 11 years, and considered parental warmth and children's psychophysiological reactivity as statistical moderators of these associations. In all, 40 children with autism spectrum disorder and their primary caregivers attended a visit involving collection of child electrodermal activity, parent-child interaction, a parent interview from which critical attitudes and warmth were coded, and parent report of child behavior problems. Criticism was directly related to higher child externalizing but not internalizing problems. Parental criticism interacted with warmth in the prediction of internalizing problems such that criticism was only associated with more problems in the context of moderate but not high warmth. Criticism was positively associated with externalizing problems under conditions of moderate and high, but not low, child electrodermal activity reactivity. Implications for conceptualizations of parental criticism in autism spectrum disorder, for understanding comorbid behavior problems in this population, and for intervention are discussed.

Caregiving processes and expressed emotion in psychosis, a cross-cultural, meta-analytic review

The construct of Expressed Emotion (EE) is a reliable predictor of relapse in psychotic disorders globally. However, cultural differences in the level and manifestation of EE have been reported. This review was conducted in line with PRISMA guidelines to demonstrate the distribution of EE and its domains cross-culturally as well as its relationship with relapse in psychosis. Ninety-six studies reported global EE scores and/or separate EE domains amongst caregivers of a family member with psychosis and used the Camberwell Family Interview (CFI) to measure EE. In the meta-analysis (k = 34, n = 1982), exposure to high EE was indicative of a 95% increased likelihood of relapse compared to low EE. However, no significant effect of geographical region on global EE scores (high/low) or EE domains was found. Several adjustments to the scoring of the CFI were highlighted based on cultural norms, particularly relevant to the domains of emotional over-involvement, warmth and criticism. Although this made meaningful quantitative comparisons across studies difficult, it nonetheless highlighted cultural considerations that need to be taken into account when interpreting EE and understanding its relationship to clinical outcomes. There is not a universal normative EE experience, with cultural variation in the scoring and interpretation of EE existing as evidenced by adjusted cut off scores and conceptualisation of EE constructs. Thus, it is important for clinical practitioners to have an awareness of different cultural norms in relation to caregiving and care receiving behaviours, which can inform adaptations to clinical interventions in multicultural settings.

Are family warmth and positive remarks related to outcomes in psychosis? A systematic review

BACKGROUND

Affective attitudes and behaviours manifested within the family environment have been characterised as expressed emotion (EE). High EE environments have been robustly shown to put psychosis patients at a greater risk of relapse compared with low EE exposure. Positive EE dimensions (warmth; positive remarks) have received far less attention than negative EE dimensions such that EE has become synonymous with a negative family atmosphere; the predictive value of positive EE dimensions is largely ignored. A systematic review examining the relationship between positive family EE and outcomes in psychosis is needed.

METHODS

A systematic search was conducted. Studies reporting bias and study quality were assessed.

RESULTS

A total of 2368 studies were identified. Of these, 27 met eligibility criteria reporting outcomes including relapse, symptomatology, social functioning and life satisfaction. Relapse was the most commonly measured outcome. Stronger evidence emerged for the association between EE warmth and outcomes compared with EE positive remarks, with effects mostly evident in the early phase of psychosis. Evidence for protective effects of warmth on relapse was found up to 9 months follow-up. No effects were evident between positive remarks and relapse. Studies assessing symptom outcomes showed inconsistent findings. Evidence for an association with social functioning was evident, primarily in at risk mental states. Warmth and positive remarks predicted life satisfaction.

CONCLUSIONS

The positive aspects of EE require further investigation with longitudinal research designs. Clinical interventions should focus not only on reducing negative aspects of EE but also foster warmth within families in the context of psychosis.

Affective and physiological reactivity to emotional comments in individuals at elevated risk for psychosis

BACKGROUND

Individuals with schizophrenia are at increased risk of relapse when they live in highly critical (i.e., high expressed emotion; EE) family environments. It remains less clear, however, how individuals at elevated risk for a psychotic disorder react to the social stress of EE. Here we examined whether individuals at elevated risk for developing schizophrenia report greater subjective changes in affect and have increased physiological reactivity after hearing critical, praising and neutral comments.

METHOD

Measures of heart rate, heart rate variability, skin conductance, and self-reported affective ratings were used to assess differential responses to EE-type stimuli in 38 individuals at elevated-risk for psychosis and 38 low-risk controls.

RESULTS

The elevated-risk group and low-risk controls, did not differ in their initial affective and physiological reactivity to criticism. However, during the recovery period following the criticism, the elevated-risk group demonstrated greater heart rate activation. They also showed more sensitivity to praise. Although elevated-risk participants initially had higher baseline levels of negative affect and heart rate, following praise, these levels reduced and became indistinguishable from the levels of low-risk controls.

CONCLUSIONS

These findings suggest that at-risk individuals may have more difficulty recovering from criticism than their self-report data might suggest. They may also derive physiological and affective benefits from praise. Important clinical implications of these findings are discussed.

A Brief Mindfulness-Based Family Psychoeducation Intervention for Chinese Young Adults With First Episode Psychosis: A Study Protocol

Family psychoeducation (FPE) has been recommended as a major component in the treatment of psychosis. Many previous studies have implemented an intensive program design that often only emphasized improvements in patients' illness outcomes but the benefits for caregivers were limited. There have been calls for a time-limited but cost-effective FPE program to mitigate the looming reality of the suffering of people with psychosis and their families. A Brief Mindfulness-Based Family Psychoeducation for psychosis program is developed to reduce caregivers' burden and promote young adult's recovery. A randomized controlled trial will be conducted to compare this intervention with an ordinary FPE intervention. Both arms will involve six sessions, with a total contact time of 12 h. 300 caregivers of young adults who have experienced first episode psychosis within last 3 years will be recruited. Program effectiveness will be assessed by comparing outcomes measuring the caregivers' burden, mental health symptoms, positive well-being, and the young adult's mental health symptoms during the study and at 9-month post-randomization. The role of expressed emotions, interpersonal mindfulness, and non-attachment in mediating these outcomes will be explored. An additional qualitative approach Photovoice is selected to explore the complex family experiences and the benefits of mindfulness from the caregivers' personal perspectives. Trial Registration: The trial is registered with the United States Clinical Trials Registry (ClinicalTrials.gov): NCT03688009.

Psychometric properties of the Spanish version of the involvement evaluation questionnaire in caregivers of patients with borderline personality disorders

The involvement evaluation questionnaire (IEQ) was created to evaluate the caregiver's experience of burden and the consequences of providing care to people with psychotic disorders. To date, the IEQ has not been validated with caregivers of people diagnosed with borderline personality disorder (BPD). The main objective of the study was to confirm the psychometric properties and factorial structure of the Spanish version of the IEQ in 151 caregivers of people with BPD, with an average age of 54.52 (SD = 9.91). Two models were tested by means of confirmatory factor analysis, following the original factor structure. The Models 1 and 2 displayed adequate fit, with comparative fit index and Tucker-Lewis index > 0.90 and root-mean-square root of approximation < 0.08; however, Model 2 was more parsimonious. The Cronbach's alphas are adequate, ranging from 0.70 to 0.85. The consequences of providing care to people with BPD had a low or moderate association with the Level of Expressed Emotion scores. IEQ scores of caregivers of people diagnosed with BPD with psychiatric comorbidity did not differ from those of caregivers of people diagnosed with BPD without psychiatric comorbidity. The IEQ has adequate psychometric properties and can be utilized to assess burden in caregivers of people with BPD.

Treatment dropout in a family-based partial hospitalization program for eating disorders

Treatment dropout is a significant challenge in the treatment of eating disorders. In day hospital/partial hospitalization program settings, little is known about factors associated with treatment dropout. The purpose of the present study was to assess factors associated with treatment dropout in a partial hospitalization program for adolescents and young adults with anorexia nervosa. Patients and parents completed self-report and interview-based measures at baseline and at end of treatment in the partial hospitalization program. Few factors were found that differentiated the two groups. Those who dropped out had lower body weight at end of treatment, were less likely to have purged in the previous month, and had fathers who scored higher on the criticism subscale of expressed emotion. Patients who are purging may be seen as having more severe symptoms, thus possibly reducing the chances of parents prematurely discontinuing treatment. Parental criticism is a potentially modifiable factor in treatment. Further research is needed to identify effective ways to reduce parental criticism, and to identify additional modifiable factors associated with treatment dropout to reduce dropout rates in this population.Level IV: Evidence obtained from multiple time series with or without the intervention, such as case studies.

A concise self-report scale can identify high expressed emotions and predict higher relapse risk in schizophrenia

PURPOSE

Although high expressed emotions (EE) is one of the most significant predictors for schizophrenic relapse, the assessment of EE is often impeded by the demanding Camberwell Family Interview (CFI) that is required to be conducted by specifically trained staff. To enable a more efficient assessment of EE, we developed the 12-item Concise Chinese Level of Expressed Emotion Scale (CCLEES) and reported its predictive and concurrent validity in this study.

METHODS

A one-year prospective study design was adopted. Totally 101 participants diagnosed with schizophrenia were recruited from the department of psychiatry of a major acute hospital in Hong Kong. CCLEES was administered and subsequent relapse information was collected from all participants. At baseline, 10 family members of the participants were also administered CFI.

RESULTS

Participants who scored above the optimal cut-off point (Score 13 on Criticism, and/or 13 on Hostility, and/or 15 on Emotional Over-involvement) showed a 6.3 times elevated 12-month schizophrenic relapse rate compared to those who scored below cut-off. The CCLEES also demonstrated excellent correspondence with CFI, the widely-recognized golden benchmark of EE assessment.

CONCLUSIONS

The results support the CCLEES as a brief and psychometrically sound self-report measurement for EE in Chinese people with schizophrenia.

Expressed emotion and socio-demographic and clinical factors in families of Brazilian patients with schizophrenia

BACKGROUND

Families are the main caregivers of people with schizophrenia. Family dynamic and expressed emotion (EE) of relatives are fundamental determinants on the course of schizophrenia.

METHOD

This study analyzed socio-demographic and clinical factors related to EE components. A total of 94 dyads (patients with schizophrenia and their relatives) were recruited from three mental health clinics. A form containing socio-demographic and clinical variables and the Brazilian version of Family Questionnaire were used and the data were analyzed through regression model.

RESULTS

Results showed that factors such as patients' occupation status and patients' age, as well as relatives' gender and the degree of relatedness, were related to emotional overinvolvement and critical comments levels.

CONCLUSION

This is the first study in the Brazilian cultural context that evaluates EE components and related factors on families of patients with schizophrenia. Other studies concerning EE on different cultural contexts and possible interventions must be carried out to help health professionals to improve patient and family care.

Expressed Emotion Research in India: A Narrative Review

BACKGROUND

Expressed emotion (EE) is detrimental to patients with schizophrenia, mood disorders, eating disorders and many other psychiatric and neurological disorders. However, majority of the EE literature is generated from the west, and the results of those studies may have limited application in Indian setting. Hence, we conducted this review with the main aim of understanding EE research in India and its potential role in the course and outcome of psychiatric disorders and other chronic illnesses.

METHODS

Using keywords, we performed searches of electronic databases (PubMed, IndMed, PsychInfo, Science-Direct and Google Scholar) and internet sources and a manual search in the bibliography of the retrieved articles to identify potential original research articles on EE in India.

RESULTS

As per the selection criteria, 19 reports of 16 studies were included and reviewed. The sample size of the EE studies ranged from 20 to 200, and majority of the studies were conducted in psychosis/schizophrenia, followed by obsessive compulsive disorder and epilepsy. Although high EE was found in most of the studies, the impact of EE on illness outcome is not well explored and only two studies examined the relationship between EE and relapse.

DISCUSSION AND CONCLUSION

There is a dearth of studies on EE, especially its relationship with relapse or clinical outcomes in the Indian context. We recommend more studies in these areas which may be helpful for clinical decisions and advancement of context knowledge in EE.

Ecological Validity of Expressed Emotion in Early Psychosis

Expressed emotion (EE) is an aspect of the family environment that influences the course of multiple forms of psychopathology. However, there is limited research about how EE dimensions [i.e., criticism and emotional over-involvement (EOI)] are expressed in real-world settings. The present study used experience sampling methodology to investigate: 1) the criterion and construct validity of daily-life, momentary measures of criticism and EOI, and 2) the construct and ecological validity of psychometric EE-dimensions as assessed with the self-report Family Questionnaire (FQ). A total sample of 55 relatives (34 relatives of at-risk mental state patients and 21 of first-episode psychosis patients) were prompted randomly six times daily for 1-week to assess their current emotional experiences and cognitive appraisals. Relatives also completed the FQ. Momentary criticism and EOI were significantly associated with the two FQ-EE dimensions respectively, supporting the criterion validity of real-world assessed EE dimensions. As hypothesized, momentary and FQ-EE dimensions were associated with decreased positive affect, as well as with appraisals of less effective coping in daily life. Only momentary EE dimensions were associated with increased momentary negative affect. Partly in contrast with our hypotheses, momentary criticism and FQ-criticism were more consistently related to situational stress and burden than momentary EOI and FQ-EOI. Finally, neither momentary nor FQ-EE dimensions showed distinct patterns of associations with illness attributions. Findings partly support the construct validity of momentary criticism and EOI as well as the construct and ecological validity of the FQ as a sensitive measure of EE dimensions.

Sex Differences In Psychoeducation For Patients With Depression: A Comparison Of Frequency And Efficacy Of Psychoeducation

BACKGROUND

We aimed to reveal sex differences in depression comprehension by reanalyzing data from a previous study of patients who were administered antidepressants.

METHODS

A total of 424 outpatients were enrolled in the study. Participants were provided an original self-administered questionnaire that comprised eight items: depressive symptoms, course of depression, cause of depression, treatment plan, duration of antidepressant use, how to discontinue antidepressants, side effects of antidepressants, and psychotherapy. Each item consisted of the following two questions: "Have you received an explanation from the doctor in charge?" and "How much do you understand about your treatment?" The level of patients' comprehension of these questions was rated on a scale of 0-10 (11 anchor points). Symptoms were evaluated using the Quick Inventory for Depressive Symptomatology, Japanese version, and other scales. Patients were divided on the basis of sex, regardless of whether they were in remission.

RESULTS

Compared with male patients, female patients with depression exhibited lower levels of depression and did not receive adequate psychoeducation from their physicians. While depression comprehension of female patients might not necessarily be associated with remission, male patients in remission received more explanations about depression and understood more compared with female patients.

CONCLUSION

Depression comprehension of male patients might be associated with remission, and psychoeducation should be sex-oriented to improve treatment responses.

A study on the Italian validation of the family questionnaire

Expressed Emotion (EE) refers to the emotional behavior and patterns of communication of relatives toward patients, and it is a strong predictor of illness outcome across a variety of psychiatric disorders. The aims of the present study were to provide a contribution for the Italian validation of the Family Questionnaire (FQ), developed by Wiedemann et al. (2002). The FQ is a self-report questionnaire to assess the EE construct. Specifically, the present study aims to examine the psychometric properties (factorial structure, internal consistency and concurrent validity) of the Italian version of the FQ and to explore the differences between mothers' and fathers' emotional responses to patients with eating disorders. The sample was composed of 199 carers of patients with eating disorders (80 males and 119 females, M _age= 49.63, SD = 6.24). Confirmatory Factor Analyses verified the original two-factor structure. The internal consistency coefficients of the two FQ dimensions were satisfactory. Further, the present study provided support for the concurrent validity of FQ, also within the Italian context.

The Association Between the Severity and Level of Understanding of Depression Among Patients Treated With Antidepressants: A Survey of 424 Outpatients in Japan

OBJECTIVES

The present study investigated the association between the severity and knowledge of depression and attempted to reveal the specific aspects of understanding associated with severity.

METHODS

A total of 424 outpatients were enrolled in this study. We used an original self-administered questionnaire: (a) the symptoms of depression, (b) the course of depression, (c) the cause of depression, (d) the treatment plan, (e) the duration of antidepressant use, (f) how to discontinue antidepressant use, (g) the adverse effects of antidepressants, and (h) psychotherapy. Each category consisted of the following questions: "How much do you understand about your treatment?" The level of understanding was rated on an 11-point scale ranging from 0 to 10. The following scales were administered: the Quick Inventory of Depressive Symptomatology, Japanese version (QIDS-J); the Global Assessment of Functioning; and the Clinical Global Impression, Severity scale. Subjects were divided in 5 groups according to severity of QIDS-J. Clinical characteristics were also investigated.

RESULTS

Based on an analysis of variance, significant differences were found among the 5 groups with regard to age at onset, duration of disease, and duration of antidepressant use. A multiple regression analysis revealed that item B significantly and negatively predicted the QIDS-J scores, whereas item C significantly and positively predicted these scores. Some multiple logistic regression models seeking to distinguish severity found that all but items E to H were significantly associated with severity.

CONCLUSIONS

Items B and C were significantly negatively and positively associated with depression severity, respectively. Sufficient and suitable psychoeducation in and knowledge of depression might improve the treatment responses in patients with depression.

Culturally adapted Family Intervention (CaFI) for African-Caribbean people diagnosed with schizophrenia and their families: a mixed-methods feasibility study of development, implementation and acceptability

Background

African-Caribbean people in the UK experience the highest incidence of schizophrenia and the greatest inequity in mental health care. There is an urgent need to improve their access to evidence-based care and outcomes. Family intervention (FI) is a National Institute for Health and Care Excellence-approved psychosocial intervention. Although clinically effective and cost-effective for schizophrenia, it is rarely offered. Evidence for any research into FI is lacking for ethnic minority people generally and for African-Caribbean people specifically.

Aims

(1) To assess the feasibility of delivering a novel, culturally appropriate psychosocial intervention within a ‘high-risk’ population to improve engagement and access to evidence-based care. (2) To test the feasibility and acceptability of delivering FI via ‘proxy families’.

Design

A mixed-methods, feasibility cohort study, incorporating focus groups and an expert consensus conference.

Setting

Two mental health trusts in north-west England.

Participants

We recruited a convenience sample of 31 African-Caribbean service users. Twenty-six family units [service users, relatives/family support members (FSMs) or both] commenced therapy. Half of the service users (n = 13, 50%), who did not have access to their biological families, participated by working with FSMs.

Interventions

An extant FI model was culturally adapted with key stakeholders using a literature-derived framework [Culturally adapted Family Intervention (CaFI)]. Ten CaFI sessions were offered to each service user and associated family.

Main outcome measures

Recruitment (number approached vs. number consented), attendance (number of sessions attended), attrition (number of dropouts at each time point), retention (proportion of participants who completed therapy sessions), and completeness of outcome measurement.

Results

Of 74 eligible service users, 31 (42%) consented to take part in the feasibility trial. The majority (n = 21, 67.7%) were recruited from community settings, seven (22.6%) were recruited from rehabilitation settings and three (9.7%) were recruited from acute wards. Twenty-four family units (92%) completed all 10 therapy sessions. The proportion who completed treatment was 77.42% (24/31). The mean number of sessions attended was 7.90 (standard deviation 3.96 sessions) out of 10. It proved feasible to collect a range of outcome data at baseline, post intervention and at the 3-month follow-up. The rating of sessions and the qualitative findings indicated that CaFI was acceptable to service users, families, FSMs and health-care professionals.

Limitations

The lack of a control group and the limited sample size mean that there is insufficient power to assess efficacy. The findings are not generalisable beyond this population.

Conclusions

It proved feasible to culturally adapt and test FI with a sample of African-Caribbean service users and their families. Our study yielded high rates of recruitment, attendance, retention and data completion. We delivered CaFI via FSMs in the absence of biological families. This novel aspect of the study has implications for other groups who do not have access to their biological families. We also demonstrated the feasibility of collecting a range of outcomes to inform future trials and confirmed CaFI’s acceptability to key stakeholders. These are important findings. If CaFI can be delivered to the group of service users with the most serious and persistent disparities in schizophrenia care, it has the potential to be modified for and delivered to other underserved groups.

Future work

A fully powered, multicentre trial, comparing CaFI with usual care, is planned.

Trial registration

Current Controlled Trials ISRCTN94393315.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 6, No. 32. See the NIHR Journals Library website for further project information.

Expressed emotion as a predictor of the first psychotic episode - Results of the European prediction of psychosis study

OBJECTIVE

To investigate the impact of expressed emotion (EE) on the risk of developing the first psychotic episode (FEP).

METHOD

The European Prediction of Psychosis Study (EPOS) investigated 245 patients who were at clinical high risk (CHR) of psychosis. The predictive value of EE alone and as a part of the multivariate EPOS model was evaluated.

RESULTS

"Perceived irritability", a domain of the Level of Expressed Emotion Scale (LEE), was found to be predictive for the First Psychotic Episode (FEP), even as an individual variable. Furthermore, it was selected in the multivariate EPOS prediction model, thereby replacing two of the original predictor variables. This led to an improved revised version that enabled the identification of three significantly different risk classes with a hazard rate of up to 0.911.

CONCLUSIONS

CHR subjects who perceive the most important person in their individual social environment to be limited in their stress coping skills had a higher risk of conversion to the first psychotic episode. The importance of this risk factor was further demonstrated by an improvement of risk estimation in the original EPOS predictor model. Perceiving a reference person as stress-prone and thus potentially unreliable might amplify self-experienced uncertainty and anxiety, which are often associated with the prodromal phase. Such an enforcement of stress-related processes could promote a conversion to psychosis.

Heterogeneous weight restoration trajectories during partial hospitalization treatment for anorexia nervosa

Early response to treatment has been shown to predict good outcome in family-based treatment, but little is known about who responds quickly.

OBJECTIVE

The purpose of the current study was to examine the short-term weight gain trajectories among youth receiving partial hospitalization program services for anorexia nervosa (AN), and to identify predictors of these trajectories.

METHOD

Adolescent and young adults (n = 102) with AN or subthreshold AN completed semi-structured interviews and self-report measures on admission to a family-based partial hospitalization program. Patients participated in programming 5 days a week.

RESULTS

Three weight gain trajectories were found to indicate slow, moderate, and rapid weight gain trajectories. All rapid responders gained at least four lbs. in the first 4 weeks of treatment, compared to 86.1% of moderate responders and 51.2% of slow responders. Patients were less likely to have a moderate or rapid response trajectory if they had a mood disorder diagnosis and higher parental expressed emotion. Additionally, the presence of compensatory behavior increased the likelihood of having a rapid response.

DISCUSSION

Despite the sometimes chronic nature of AN, most patients fell into one of the two favorable response trajectories. The identification of these trajectories underscores the importance of considering the core disordered eating behaviors (i.e., restricting, binge eating, and purging), comorbid psychopathology, and parental expressed emotion.

Family intervention for caregivers of people with recent-onset psychosis: A systematic review and meta-analysis

AIM

We aimed to systematically review the evidence of the effectiveness of family interventions for caregivers of people with recent-onset psychosis compared with usual psychiatric care. A secondary objective was to directly compare the effects of different types of family interventions.

METHODS

MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL Complete and EBSCOhost were searched to identify relevant randomized controlled trials. Trial data were extracted following the procedures described in the Cochrane Handbook of systematic reviews. Random-effects models were used to pool the intervention effects.

RESULTS

Twelve studies including 1644 participants were included in this review. With the exception of a high risk of performance bias inherent to the nature of the psychosocial interventions, the studies had an overall low or unclear risk of bias, suggesting that sources of bias are unlikely to lower confidence in the estimate of intervention effects. Meta-analyses were conducted for 4 different participant outcomes reported in 9 studies. Compared with usual psychiatric care, family intervention was more effective in reducing care burden over all follow-up periods. Family intervention was also superior to usual care with regards to caregiving experience in the short term and improved utilization of formal support and family functioning over longer-term follow up. Mutual support is more effective than psychoeducation in improving family functioning when measured 1 to 2 years after the intervention but had equivalent effects on utilization of formal support services.

CONCLUSIONS

This review provides evidence that family intervention is effective for caregivers of recent-onset psychosis, especially for care burden where the positive effects are enhanced over time.

The characteristics of understanding of depression among older patients treated with antidepressants: a comparison between older and younger patients

BACKGROUND

To reveal characteristics of understanding of depression among older patients, we reanalyzed the data from a previous study of patients who were administered antidepressants.

METHODS

A total of 424 outpatients were enrolled in this study. We used an original self-administered questionnaire consisting of eight items: depressive symptoms, the course of depression, the cause of depression, the treatment plan, the duration of antidepressant use, how to discontinue antidepressants, the side effects of antidepressants, and psychotherapy. Each item consisted of the following two questions: "Have you received an explanation from the doctor in charge?" and "How much do you understand about your treatment?". The level of understanding was rated on a scale of 0-10 (11 anchor points). Subjects were divided into two groups: younger patients who were <65 years of age and older patients who were ≥65 years of age.

RESULTS

Older patients with depression showed lower levels of understanding of depression and did not receive sufficient psychoeducation from their physicians, but their understanding of depression might not be associated with their remission. In the younger group, the scores of understanding of the course of depression, the treatment plan, how to discontinue antidepressants, and psychotherapy items, and the total understanding score of remitters, were significantly higher than those of non-remitters. In contrast, there were no significant differences in the items score or total score between remitters and non-remitters in the older group.

CONCLUSION

Older patients showed lower levels of understanding of depression and did not appear to receive sufficient psychoeducation, but their understanding of depression might not be associated with their remission.

Expressed Emotion, Shame, and Non-Suicidal Self-Injury

A cross-sectional study examining relationships between perceived family Expressed Emotion and shame, emotional involvement, depression, anxiety, stress and non-suicidal self-injury, in 264 community and online adults (21.6% male). We compared self-injurers with non-self-injurers, and current with past self-injurers. Self-injurers experienced more family Expressed Emotion (EE) than non-injurers (t(254) = −3.24, p = 0.001), linear contrasts explaining 6% of between-groups variability (F(2, 254) = 7.36, p = 0.001, η² = 0.06). Differences in EE between current and past self-injurers were not significant. Overall shame accounted for 33% of between-groups variance (F(2, 252) = 61.99, p < 0.001, η² = 0.33), with linear contrasts indicating self-injurers experienced higher levels compared to non-injurers (t(252) = −8.23, p < 0.001). Current self-injurers reported higher overall shame than past self-injurers (t(252) = 6.78, p < 0.001). In further logistic regression, emotional involvement and overall shame were the only significant predictors of self-injury status. With every one-unit increase in emotional involvement, odds of currently engaging in self-injury decreased by a factor of 0.860. Conversely, a one-unit increase in overall shame was associated with an increase in the odds of being a current self-injurer by a factor of 1.05. The findings have important treatment implications for engaging key family members in intervention and prevention efforts.

The effects of psychoeducational family intervention on coping strategies of relatives of patients with bipolar I disorder: results from a controlled, real-world, multicentric study

Background

Psychoeducational family intervention (PFI) has been proven to be effective in improving the levels of family burden and patients' personal functioning in schizophrenia and bipolar disorders (BDs). Less is known about the impact of PFI on relatives' coping strategies in BD.

Methods

A multicenter, controlled, outpatient trial funded by the Italian Ministry of Health and coordinated by the Department of Psychiatry of the University of Campania "Luigi Vanvitelli" has been conducted in patients with bipolar I disorder (BD-I) and their key relatives consecutively recruited in 11 randomly selected Italian community mental health centers. We aim to test the hypothesis that PFI improves problem-oriented coping strategies in relatives of BD-I patients compared to the Treatment As Usual (TAU) group.

Results

The final sample was constituted of 123 patients and 139 relatives. At baseline assessment (T0), the vast majority of relatives already adopted problem-oriented coping strategies more frequently than the emotion-focused ones. At the end of the intervention, relatives receiving PFI reported a higher endorsement of adaptive coping strategies, such as "maintenance of social interests" (odds ratio [OR]=0.309, CI=0.04-0.57; p=0.023), "positive communication with the patient" (OR=0.295, CI=0.13-0.46; p=0.001), and "searching for information" (OR=0.443, CI=0.12-0.76; p=0.007), compared to TAU relatives, after controlling for several confounders. As regards the emotion-focused coping strategies, relatives receiving the experimental intervention less frequently reported to adopt "resignation" (OR=-0.380, CI=-0.68 to -0.08; p=0.014) and "coercion" (OR=-0.268, CI=-0.46 to -0.08; p=0.006) strategies, compared to TAU relatives.

Conclusion

PFI is effective in improving the adaptive coping strategies of relatives of BD-I patients, but further studies are needed for evaluating the long-term benefits of this intervention.

Highlighting the Way Forward: A Review of Community Mental Health Research and Practice Published in AJCP and JCP

Articles published in the two most prominent journals of community psychology in North America, the American Journal of Community Psychology (AJCP) and Journal of Community Psychology (JCP), provide a clear indicator of trends in community research and practice. An examination of community psychology's history and scholarship suggests that the field has reduced its emphasis on promoting mental health, well-being, and liberation of individuals with serious mental illnesses over the past several decades. To further investigate this claim, the current review presents an analysis of articles relevant to community mental health (N = 307) published in the American Journal of Community Psychology (AJCP) and Journal of Community Psychology (JCP) from 1973 to 2015. The review focuses on article characteristics (e.g., type of article and methods employed), author characteristics, topic areas, and theoretical frameworks. Results document a downward trend in published articles from the mid-1980s to mid-2000s, with a substantial increase in published work between 2006 and 2015. A majority of articles were empirical and employed quantitative methods. The most frequent topic area was community mental health centers and services (n = 49), but the past three decades demonstrate a clear shift away from mental health service provision to address pressing social issues that impact community mental health, particularly homelessness (n = 42) and community integration of adults with serious mental illnesses (n = 40). Findings reflect both the past and present state of community psychology and suggest promising directions for re-engaging with community mental health and fostering well-being, inclusion, and liberation of adults experiencing serious mental health challenges.

Family psychoeducation for people living with schizophrenia and their families

Most people with schizophrenia have frequent contact with their families. Therefore, the family should be involved in their relative's treatment and care wherever possible, so that they can contribute to that person's recovery and the family's own needs for information, support and treatment can be addressed. Family psychoeducation refers to a group of structured psychotherapeutic interventions that involve the person with schizophrenia and their family as partners in care. Trained practitioners adopt a collaborative approach to information sharing and provide training in coping, communication and problem-solving skills. This article describes the common principles and techniques of family psychoeducation (FPE), along with the substantial evidence for its benefits for families, especially reduced relapse rates for the person with schizophrenia. Despite recommendations in clinical practice guidelines, FPE is not widely available throughout the world. The current challenge is to address this through systemic approaches to practice change and tiered approaches to family service delivery.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

Attitudes of the general population to psychiatric and physical illness

Aims and method

The attitudes of members of the general population to people with psychiatric and physical illnesses were examined. We took a random sample of 280 members of the general population listed in the phone directory and sent them a brief clinical vignette about a neighbour with either schizophrenia, depression, diabetes or no illness.

Results

Only 103 (41%) of the surveyed general population responded. Some unsolicited comments revealed negative attitudes from a small number of subjects. There were, however, no statistically significant differences in general attitudes to sufferers of psychiatric and physical illnesses suggestive of discrimination against the former. Indeed, respondents showed a general tendency to be more supportive of a neighbour with any illness than to those without. In a sub-analysis, however, those who knew someone with schizophrenia were significantly less likely to be sympathetic towards them.

Clinical implications

We have not detected any general stigmatisation of those with psychiatric disorders, but our results may be attributable to response bias. Discrimination against those with psychiatric disorder may be limited to a relatively small sector of society or may only be manifest in relatively close relationships.

Stress and the genesis of diabetes mellitus in schizophrenia

Background

The incidence of diabetes mellitus is higher in patients with schizophrenia than in the general population. Antipsychotic drugs have been implicated in the development of diabetes, but as non-medicated patients with schizophrenia have high rates of diabetes it is likely that factors other than medication are involved.

Aim

To examine the role of stress in the emergence of diabetes mellitus in patients with schizophrenia.

Method

Selective literature review.

Results

A model is developed suggesting that patients with schizophrenia show overactivation of both the hypothalamic–pituitary–adrenal and sympathoadrenal medullary axes, manifested by increased production of cortisol and adrenaline. Both of these hormones are known to be diabetogenic and are proposed as playing a part in the onset of diabetes mellitus in schizophrenia.

Conclusions

Stress has an important role in the onset of schizophrenia and may also play a part in relapse. Further research is needed to clarify the extent to which stress accounts for the genesis of diabetes in such patients.

Needs of the families of people with schizophrenia

Family therapy for schizophrenia began in the early 1950s, inspired by theories that located the cause of the illness in family dysfunction. The family pathology was seen as stemming from disturbed relationships (Fromm-Reichmann, 1948; Lidz et al, 1956; Laing & Esterson, 1964) and / or distorted communication (Bateson et al, 1956; Wynne & Singer, 1963).

Outcome research in family therapy

The family and therapy

The term family therapy can be misleading. ‘Family’ is open to many interpretations, if not attacks, because it is frequently read as implying a two-parent, heterosexual couple with two children, with the woman primarily the ‘homemaker’ and the man the ‘breadwinner’, with occasional backup from the grandparents. Such a picture would seem to marginalise or exclude other family forms, such as childless couples, single parents with children, gay or lesbian couples and unattached elderly persons. However, the reality is that family therapists treat many different forms of committed relationships and friendships. As to the term therapy, it tends to imply the presence of illness or dysfunction, located in the family rather than one of its individual members, and may thus be quite unacceptable to families who often believe that it is the patient and not them whom requires help. Being at the receiving end of family therapy can have strong connotations of blame. Practitioners therefore increasingly use the term systemic therapy, which is also more informative because some of the work often involves the wider system. The systemic approach is essentially a contextual approach – seeing and treating people in context.

Expressed emotion across cultures

Expressed emotion has been used as a construct in understanding the interaction between patients and their carers and families. A considerable amount of data from Western cultures suggests that high expressed emotion can lead to relapse in vulnerable individuals, even when they are on medication. However, the data from other cultures are less solid. This paper reviews some of the existing findings and recommends that various components of expressed emotion must be seen in the cultural context and embedded in the normative data of the population before the concept can be considered in association with the pathogenesis of relapse.

Integrated treatment of first-episode psychosis: effect of treatment on family burden

Background

The families of patients with first-episode psychosis often play a major role in care and often experience lack of support.

Aims

To determine the effect of integrated treatment v. standard treatment on subjective burden of illness, expressed emotion (EE), knowledge of illness and satisfaction with treatment in key relatives of patients with a first episode of schizophrenia-spectrum disorder.

Method

Patients with ICD-10 schizophrenia-spectrum disorders (first episode) were randomly assigned to integrated treatment or to standard treatment. Integrated treatment consisted of assertive community treatment, psychoeducational multi-family groups and social skills training. Key relatives were assessed with the Social Behaviour Assessment Schedule (SBAS, burden of illness), the 5-min speech sample (EE), and a multiple choice questionnaire at entry and after 1 year.

Results

Relatives in integrated treatment felt less burdened and were significantly more satisfied with treatment than relatives in standard treatment. There were no significant effects of intervention groups on knowledge of illness and EE.

Conclusions

The integrated treatment reduced family burden of illness and improved satisfaction with treatment.