Efficacy of a psychoeducational intervention in improving relatives' knowledge about schizophrenia and reducing rehospitalisation

Family psychoeducation to improve outcome in caregivers and patients with schizophrenia: a randomized clinical trial

Introduction

Schizophrenia is recognized for its severe impact on both patients and caregivers. In a 12-month follow-up randomized clinical trial, we aimed to measure the efficacy of a brief family psychoeducation program in terms of reducing relapse risk and improving medication adherence in patients, as well as reducing caregiver burden, depression and increasing knowledge of the illness.

Methods

A total of 25 days of patients with schizophrenia (DSM-IV-TR) and family primary caregivers were recruited in a single regional psychiatric outpatient facility located in Bordeaux. In the active group, caregivers received a psychoeducational intervention consisting of six sessions spread over 1.5 months, while the control group was placed on a waiting list. Sociodemographic, symptom severity (PANSS) and medication adherence (MARS) from patients were assessed at baseline and relapse rates was recorded during the 12 months follow-up period. Caregivers' burden (ZBI), depression (CES-D), quality of life (S-CGQoL), knowledge of the disease (KAST) and therapeutic alliance (4PAS-C) were assessed at baseline, three and 6 months.

Results

On the 25 patients included, the mean age was 33.3 years (SD = 9.7) with a mean duration of disease of 7.48 years (SD = 7.1). On the 25 caregivers included, the mean age was 50.6 years (SD = 14.0). Twenty-one were female (84.0%), 12 were married (48.0%) and 11 lived alone (44.0%). For patients, the family psychoeducation intervention significantly reduced the risk of relapse with a significant effect found at 12 months follow-up (p = 0.014). No change was observed on medication adherence. For caregivers, the intervention reduced the burden (p = 0.031), decreased the depression (p = 0.019), and increased the knowledge on schizophrenia (p = 0.024). Analyzes for repeated measures showed a statistically significant difference in therapeutic alliance (p = 0.035).

Conclusion

As confirmed by previous studies, the brief multifamily program (consisting of six sessions over a period of 1.5 months) was found to be effective in improving outcomes for caregivers (e.g., burden, depression, knowledge) and patients (e.g., preventing relapse) in the context of routine care. Given its short duration, this program is expected to be easily implementable within the community.

Clinical trial registration

https://clinicaltrials.gov/, NCT03000985.

Exploring Discharge Outcomes and Readmission Rates of Mothers Admitted to a Psychiatric Mother and Baby Unit

To evaluate change in Health of the Nation Outcome Scale (HoNOS) scores from admission to discharge, readmission rates after 28-day and six months post-discharge, and factors associated with readmission in a Mother and Baby Unit (MBU). An exploratory cohort study was completed of mother-infant dyads admitted to a public psychiatric MBU in Australia between March 2017 and August 2018 (18 months). Admission and discharge scores on the clinician-rated Health of the Nation Outcome Scale (HoNOS) were compared using dependent samples t-tests. The frequency of readmission to any psychiatric inpatient unit within six months of discharge was determined from medical records. Characteristics of mothers who were and were not readmitted were evaluated. Of the 82 mother-infant dyads admissions, 12 (14.63%) women were readmitted within six months, and six (7.31%) were readmitted within 28-days. Total HoNOS scores significantly improved between admission and discharge (t₍₈₁₎=9.45, p<.000). Descriptive statistics for demographics, diagnoses, Mental Health Act status and discharge supports were computed for women readmitted and not readmitted. While these readmission rates and HONOS scores reflect a successful MBU admission, further research is required with larger sample sizes and more specific maternal and infant mental health outcome measures.

Determinants of burden in caregivers of patients with exacerbating schizophrenia

Purpose

Restriction in involuntary hospital admission and reduced lengths of inpatient stay increase burden on relatives of individuals with schizophrenia. This study aims at assessing the relationship between caregiver burden and behavioural disturbances of the affected, e.g. threats, nuisances, but also substance use and aggression. Two weeks before the last hospitalisation of the affected are considered as being the most burdensome period for relatives.

Subjects and methods

Sixty-four relatives of schizophrenic patients were assessed by the semi-structured “Interview for Measuring the Burden on the Family”. Subscales and total scales of burden were calculated. Predictors were identified by regression analyses.

Results

The most important predictor of burden is burden in the relationship between caregiver and the affected representing the changes in the relationship occurring in acute illness. Threats, nuisances, time spent with the affected, and burden due to restricted social life and leisure activities were additional predictors, but not aggression or substance abuse. Eighty-five percent of the cases could be assigned correctly.

Discussion and conclusions

To better encounter burden, relatives should learn to cope with disturbing behaviour of and altered relationship to the affected, but also with their own needs. Finally, relatives must be included in the decision whether or not an affected person should be hospitalised.

Gender differences in patient and caregiver psychoeducation for schizophrenia

Objective:

The aim of this research is to detect gender-related differences in patients and caregivers regarding knowledge about schizophrenia and attitudes towards drugs as well as gender as predictor for changes in these variables during psychoeducation.

Methods:

Data sets of one randomised-controlled (study 1) and one naturalistic psychoeducation study (study 2) were reanalysed. Main outcome measures (knowledge about schizophrenia, drug attitude, confidence in medication) were assessed at baseline, post-intervention and 12 months after index discharge.

Results:

The reanalysed samples consisted in total of 1002 patients and 176 caregivers. In study 2, baseline knowledge was significantly better in male patients and female caregivers. All participants improved significantly their knowledge. The amount of knowledge gain did not differ between genders in either study or either group. Gender was not a major predictor of baseline knowledge or knowledge gain. Only in study 1 did gender significantly impact the knowledge gain from baseline to follow-up. Regarding improvement of drug attitude, females seemed to benefit significantly better from psychoeducation. In both studies, however, changes in drug attitudes respectively confidence in medication were best explained by lower corresponding baseline scores, not gender. Patients’ gender did not influence outcomes of their caregivers.

Conclusion:

Our findings suggest that psychoeducational programs might be better adapted to males in order to improve their drug attitude. Concerning knowledge, gender-related changes do not seem to be necessary.

Caregiver psychoeducation for first-episode psychosis

Introduction

International best-practice guidelines for the management of first-episode psychosis have recommended the provision of psychoeducation for multifamily groups. While there is ample evidence of their efficacy in multiepisode psychosis, there is a paucity of evidence supporting this approach specifically for first-episode psychosis. We sought to determine whether a six-week caregiver psychoeducation programme geared specifically at first-episode psychosis improves caregiver knowledge and attitudes.

Methods

Caregivers of people with first-episode psychosis completed a 23-item adapted version of the self-report Family Questionnaire (KQ) and a 17-item adapted version of the self-report Drug Attitudes Inventory (DAI) before and after the six-week DETECT Information and Support Course (DISC). Using a Generalised Linear Repeated Measures Model, we analyzed the differences in proportions of correct answers before and after the programme.

Results

Over a 24-month study period, 31 caregivers (13 higher socioeconomic; 13 lower socioeconomic; five unspecified socioeconomic; 19 female; 12 male) participated in the DISC programme and completed inventories before and after the course. Knowledge of psychosis and specific knowledge of medication treatment improved among caregivers overall (p < .01; effect sizes 0.78 and 0.94 respectively). There were no significant gender or socioeconomic differences in any improvement.

Discussion

This study confirms that caregiver psychoeducation specifically for first-episode psychosis directly improves knowledge of the illness overall and, in particular, knowledge of medication. Gender is not a factor in this, while the lack of any socioeconomic differences dispels the myth that patients in lower socioeconomic groups are disadvantaged because their caregivers know less.

Schizophrenia: A five-year follow-up of patient outcome following psycho-education for caregivers

Introduction

There is evidence that psycho-education courses for caregivers of individuals with schizophrenia improve the short-term outcome of the condition. However, most of the outcome studies are limited to two-year follow-up.

Materials and methods

This study is a five-year retrospective case-control follow-up of an original cohort of 63 patients and their 101 caregivers who completed a six-week Caregiver Psycho-education Programme (CPP) for schizophrenia and psychosis between 2002 and 2005, and 60 controls, matched for age, gender and severity of their psychotic illness.

Results

Patients whose caregivers learned more from the six-week psycho-education course had a significantly longer time to relapse (P = 0.04) and a significantly shorter length of stay during their first relapse (P < 0.05). Patients whose caregivers attended the six-week psycho-education course (regardless of how much the caregivers learned) had a significantly better outcome than controls. This included a significantly smaller number of relapses (P < 0.01), longer time to relapse (P < 0.01), shorter length of stay during their first relapse (P < 0.01) and smaller number of bed days over five years (P < 0.01). The odds ratio of controls relapsing, although insignificant at one year, was 4.13 (1.85–9.21) at five years. Outcome was not affected by either the numbers of caregivers attending for each patient, or caregiver gender.

Discussion and conclusions

This study, which is among the first to examine outcome over five years, supports the efficacy of psycho-education for caregivers in improving outcome for patients. Caregivers should be encouraged to take up psycho-education where it is available.

The effect of a family intervention on primary caregivers psychological outcomes: Findings from the integrative literature review

AIMS

This literature review examines the effectiveness of the family interventions (FIs) targeted at the primary caregivers of people diagnosed with schizophrenia on improving the knowledge level of schizophrenia and health-related outcomes.

METHODS

A total of nine studies were reviewed from December 1999 to May 2017. The methods described by the Center for Reviews and Dissemination were used to guide this review.

RESULTS

The FIs showed consistent improvement in the knowledge level of schizophrenia among participants for various follow-up intervals. In addition, FIs were found to be superior to treatment as usual in influencing health-related outcomes.

CONCLUSIONS

Implications of the findings for mental healthcare practice to include primary caregivers with the patient in the treatment process.

Modifying illness beliefs in recent onset psychosis carers: Evaluating the impact of a cognitively focused brief group intervention in a routine service

AIMS

At first-episode psychosis (FEP), many patients will be routed within familial networks and supported by informal carers who are predominately close family members such as parents. Carer burden, distress and poorer coping styles are associated with different illness beliefs. The current study sought to examine the impact and acceptability of a 3 session, cognitively informed, group intervention targeting illness beliefs previously linked to distress and poorer caregiving experiences in FEP carers.

METHODS

Carers attending a routine FEP service were invited to attend the group intervention and completed a measure of illness beliefs at baseline and post intervention.

RESULTS

Data on 68 carers with complete datasets are presented. Carers were predominately females (64.2%). Group attendance was linked to positive improvements in carer baseline beliefs about the negative consequences of the illness for the patient and themselves, attributions of blame about the illness to the patient and themselves and their overall understanding about the illness. Significant improvements in their understanding of the illness timeline and course, and confidence in dealing with difficulties were also identified.

CONCLUSIONS

A cognitively informed group approach to targeting the less adaptive illness beliefs reported by FEP carers may offer an effective and acceptable pathway to facilitate their understanding of the illness and adjustment. Further studies using controlled designs are required.

Short term effects of brief need based psychoeducation on knowledge, self-stigma, and burden among siblings of persons with schizophrenia: A prospective controlled trial

Siblings of persons with schizophrenia are important in providing long-term social support to the patients. Interventions addressing their needs are very sparse. Hence, this study aimed at testing the short-term effects of brief need based psychoeducation on knowledge, self-stigma, and burden among siblings of persons with schizophrenia. In this prospective controlled open label trial, 80 siblings of persons with schizophrenia were allocated in equal numbers to the brief need based psychoeducation group and the treatment-as-usual group. The outcomes were measured at baseline, and after the first and third month post-intervention. RM-ANCOVA was conducted to test the effect of the brief psychoeducation on outcome scores. The groups were similar with respect to socio-demographic, clinical, and outcome scores at the baseline. There was a significant group×time interaction effect on knowledge (F=8.71; p<0.01; η_p²=0.14) and self-stigma scores (F=14.47; p<0.001; η_p²=0.21), wherein the brief psychoeducation group showed a significant increase in knowledge and reduction in self-stigma with medium effect size through baseline to the third month follow-up as compared to the treatment as usual group. We also observed a significant main effect of time; irrespective of the group allocation, there was a significant increase in the knowledge through baseline to third month follow-up (F=5.69; p=0.02; η_p²=0.09). No main or interaction effects of group and time were observed on burden. The findings suggest that brief need based psychoeducation may increase knowledge about the illness and reduce self-stigma. Further systematic studies are warranted to test this intervention for long-term effects.

Family Functioning in First-Episode and Chronic Psychosis: The Role of Patient's Symptom Severity and Psychosocial Functioning

The aim of the present study was to assess the relationship between illness-related characteristics, such as symptom severity and psychosocial functioning, and specific aspects of family functioning both in patients experiencing their first episode of psychosis (FEP) and chronically ill patients. A total of 50 FEP and 50 chronic patients diagnosed with schizophrenia or bipolar disorder (most recent episode manic severe with psychotic features) and their family caregivers participated in the study. Family functioning was evaluated in terms of cohesion and flexibility (FACES IV Package), expressed emotion (FQ), family burden (FBS) and caregivers' psychological distress (GHQ-28). Patients' symptom severity (BPRS) and psychosocial functioning (GAS) were assessed by their treating psychiatrist within 2 weeks from the caregivers' assessment. Increased symptom severity was associated with greater dysfunction in terms of family cohesion and flexibility (β coefficient -0.13; 95 % CI -0.23, -0.03), increased caregivers' EE levels on the form of emotional overinvolvement (β coefficient 1.03; 95 % CI 0.02, 2.03), and psychological distress (β coefficient 3.37; 95 % CI 1.29, 5.45). Family burden was found to be significantly related to both symptom severity (β coefficient 3.01; 95 % CI 1.50, 4.51) and patient's functioning (β coefficient -2.04; 95 % CI -3.55, -0.53). No significant interaction effect of chronicity was observed in the afore-mentioned associations. These findings indicate that severe psychopathology and patient's low psychosocial functioning are associated with poor family functioning. It appears that the effect for family function is significant from the early stages of the illness. Thus, early psychoeducational interventions should focus on patients with severe symptomatology and impaired functioning and their families.

Burden on Caregivers of Patients with Schizophrenia and Related Factors

INTRODUCTION

Caregivers of patients with schizophrenia are under the burden of continuous and difficult processes. Determination of the factors related to caregiver burden in schizophrenia may help find strategies to decrease the burden. This study aimed at investigating the factors associated with caregiver burden among relatives of patients with schizophrenia.

METHODS

Eighty-eight caregivers of patients under treatment for schizophrenia for at least 1 year were included in the study. The Zarit Caregiver Burden Interview was used for the assessment of caregiver burden. Sociodemographical data, the level of knowledge about schizophrenia, clinical impression scale, and global assessment of functioning were used to evaluate the related factors.

RESULTS

Caregiver burden was negatively correlated with income level and functionality of the patient and was positively correlated with the age of the caregiver, the daily time spent with the patient, and the number of hospitalizations of the patient (p<0.05). There was no significant correlation between the caregivers' knowledge about schizophrenia and caregiver burden (p<0.05). Living in the same house with the patient was a positive predictor, whereas functionality and income level of the patient and education level of the caregiver were negative predictors (p<0.05).

CONCLUSION

This study highlighted the importance of setting targets for improving the functionality of patients in the design and implementation of rehabilitation and support programs for patients with schizophrenia. Additionally, providing higher income for patients, creating conditions for an independent life, and increasing incentives for younger caregivers with a higher educational level may help decrease caregiver burden.

Objective and subjective burden in relatives of patients with schizophrenia and its influence on care relationships in Chile

This study examined the burden on family members of patients with schizophrenia in a Chilean community. Sixty-five caregivers underwent the Subjective and Objective Family Burden Interview. The results showed moderate to high levels of subjective burden and low levels of support from others in providing care. Burden and containment of disturbed behaviour were correlated with worse relationships between patients and caregivers, with the latter spending less time working outside the home. The assessed sample showed a similar pattern of burden to that of caregivers from developed countries; however, the extent of the burden tended to be higher in Chilean caregivers.

Impaired family functioning in psychosis and its relevance to relapse: a two-year follow-up study

BACKGROUND

The aim of the present study was to investigate whether dysfunctional family functioning contributes to relapse over a two-year follow-up period in patients experiencing their first episode of psychosis (FEP) and chronic patients with psychosis.

METHODS

The sample consisted of 100 remitted patients (50 FEP and 50 chronic) diagnosed with schizophrenia (82%) or bipolar disorder with most recent episode manic severe with psychotic features (18%) recruited from the Inpatient Psychiatric Unit of the University Hospital of Heraklion, Crete, Greece, and their family caregivers. Family functioning was assessed in terms of cohesion and flexibility (FACES-IV), expressed emotion (FQ), family burden (FBS) and caregivers' psychological distress (GHQ-28). Relapse was defined as patient rehospitalisation due to acute psychotic exacerbation, while number, length, and type of hospitalisations were also evaluated.

RESULTS

Dysfunctional family functioning in terms of cohesion and flexibility was not found to be a significant risk factor for relapse in psychosis. High expressed emotion, as indexed primarily by increased levels of criticism rather than emotional over-involvement, was associated with increased risk of relapse and shorter time to relapse (HR=0.48, 95% CI: 0.24, 0.98, p=0.043). Similarly, high levels of family burden were related to shorter time to relapse (HR=0.47, 95% CI: 0.23, 0.95, p=0.037), whereas there was no significant difference in survival curves based on caregivers' psychological distress. No significant interaction effect of illness chronicity was observed in the aforementioned associations.

CONCLUSION

These findings highlight caregivers' criticism and burden of care as long-term predictors of the course of psychosis from the early stages of the illness and later on. In contrast, unbalanced levels of cohesion and flexibility in the family, as well as caregivers' high emotional over-involvement and psychological distress do not appear to be factors that contribute to patient relapse. Family psychoeducational interventions focusing at ameliorating caregivers' negativity toward the patient, and easing the burden of care should be considered as means in reducing relapse.

Caregivers' perceptions of coercion in psychiatric hospital admission

While knowledge on service users' perspective on their admissions to psychiatric wards has improved substantially in the last decade, there is a paucity of knowledge of the perspectives of caregivers. This study aimed to determine caregiver's perception of the levels of perceived coercion, perceived pressures and procedural justice experienced by service users during their admission to acute psychiatric in-patient units. The perspective of caregivers were then compared to the perspectives of their related service users, who had been admitted to five psychiatric units in Ireland. Caregivers were interviewed using an adapted version of the MacArthur admission experience interview. Sixty-six caregivers participated in this study and the majority were parents. Seventy one percent of service users were admitted involuntarily and nearly half had a diagnosis of schizophrenia or schizoaffective disorder. Caregivers of involuntarily admitted individuals perceived the service users' admission as less coercive than reported by the service users. Caregivers also perceived a higher level of procedural justice in comparison to the level reported by service users. Reducing the disparity of perceptions between caregivers and service users could result in caregivers having a greater understanding of the admission process and why some service users may be reluctant to be admitted.

Toward the early recognition of psychosis among Spanish-speaking adults on both sides of the U.S.-Mexico border

Lack of knowledge about psychosis, a condition oftentimes associated with serious mental illness, may contribute to disparities in mental health service use. Psychoeducational interventions aimed at improving psychosis literacy have attracted significant attention recently, but few have focused on the growing numbers of ethnic and linguistic minorities in countries with large immigrant populations, such as the United States. This paper reports on 2 studies designed to evaluate the effectiveness of a DVD version of La CLAve, a psychoeducational program that aims to increase psychosis literacy among Spanish-speaking Latinos. Study 1 is a randomized control study to test directly the efficacy of a DVD version of La CLAve for Spanish speakers across a range of educational backgrounds. Fifty-seven medical students and 68 community residents from Mexico were randomly assigned to view either La CLAve or a psychoeducational program of similar length regarding caregiving. Study 2 employed a single-subjects design to evaluate the effectiveness of the DVD presentation when administered by a community mental health educator. Ninety-three Spanish-speakers from San Diego, California completed assessments both before and after receiving the DVD training. Results from these 2 studies indicate that the DVD version of La CLAve is capable of producing a range of psychosis literacy gains for Spanish-speakers in both the United States and Mexico, even when administered by a community worker. Thus, it has potential for widespread dissemination and use among underserved communities of Spanish-speaking Latinos and for minimizing disparities in mental health service use, particularly as it relates to insufficient knowledge of psychosis.

Caregivers consequences of care among patients with eating disorders, depression or schizophrenia

BACKGROUND

The consequences of caring for a person with a mental illness can impose a substantial burden. Few studies have compared this burden among caregivers of patients with eating disorders and other mental illnesses. The objective of this study was to compare caregiver consequences in eating disorders (ED) with caregiver consequences in depression and schizophrenia, assessed with the same instrument, the Involvement Evaluation Questionnaire (IEQ). Another aim was to identify factors that may predict these consequences.

METHODS

We conducted a cross-sectional study involving 251 caregivers of ED patients; 252 caregivers of patients with depression; and 151 caregivers of patients with schizophrenia. Caregivers completed the Involvement Evaluation Questionnaire EU Version (IEQ-EU). Descriptive statistics, ANOVA, and Chi-square were applied to examine the inter-variable relationships. Consequences- indexes were also computed.

RESULTS

In all samples, worrying was the most commonly reported consequence of caregiving. Predictive variables for a high level of caregiver burden included being a mother or partner of the person being cared for (p = <.01), and being a caregiver of a patient with ED.

CONCLUSIONS

The burden of caregiving is higher among caregivers of patients with eating disorders patients than among caregivers of patients with depression or schizophrenia. Our findings suggest that caregivers of patients with an ED could benefit from providing adequate assessment and support.

Perceived risk of relapse and role of medication: comparison between patients with psychosis and their caregivers

PURPOSE

Studies have suggested that appraisal of relapse risk and knowledge of medications in relapse prevention may shape one's reactions towards an illness and treatment, and influence the illness outcome. The aim of this study is to explore patients' and caregivers' knowledge of medications, perceived chances of relapse and its predictors, as well as their relations with medication adherence.

METHODS

Eighty patient-caregiver dyads participated in the study. Their knowledge about psychosis, specific knowledge about medications and course of illness of their own and their relatives, medication adherence and symptomatology of patients were assessed. Differences in knowledge between patients and caregivers were compared. The link between adherence with perceived relapse risk and consequences of stopping medication were explored. Multinomial regression analyses were performed to examine predictors of perceived relapse risk.

RESULTS

More patients underestimated their chance of relapse and were unaware that stopping medication may lead to relapse. The lack of understanding about the effect of stopping medication of both caregivers and patients was related to poor medication adherence of patients. Patients perceived of having higher chance of relapse had more severe positive symptoms. Positive symptoms of patients and greater knowledge about psychosis of caregivers were related to higher caregivers' perceived relapse risk of their relative.

CONCLUSIONS

This study explored the views of patients and their caregivers on the perceived risk of relapse and role of medication in preventing relapse, and the potential significance. Specific interventions addressing these areas should be considered in developing relapse prevention programs.

Family functioning in families of first-episode psychosis patients as compared to chronic mentally ill patients and healthy controls

The present study aimed to investigate possible differences in family environment among patients experiencing their First Episode of Psychosis (FEP), chronic patients and controls. Family cohesion and flexibility (FACES-IV) and psychological distress (GHQ-28) were evaluated in families of 50 FEP and 50 chronic patients, as well as 50 controls, whereas expressed emotion (FQ) and family burden (FBS) were assessed in families of FEP and chronic patients. Multivariable linear regression analysis, adjusted for confounders, indicated impaired cohesion and flexibility for families of FEP patients compared to controls, and lower scores for families of chronic patients compared to those of FEP patients. Caregivers of chronic patients scored significantly higher in criticism, and reported higher burden and psychological distress than those of FEP patients. Our findings suggest that unbalanced levels of cohesion and flexibility, high criticism and burden appeared to be the outcome of psychosis and not risk factors triggering the onset of the illness. Furthermore, emotional over-involvement both in terms of positive (i.e. concern) and negative behaviors (i.e. overprotection) is prevalent in Greek families. Psychoeducational interventions from the early stages of the illness should be considered to promote caregivers' awareness regarding the patients' illness, which in turn, may ameliorate dysfunctional family interactions.

Risk and protective factors for relapse among individuals with schizophrenia: a qualitative study in Dar es Salaam, Tanzania

BACKGROUND

Relapse in people with schizophrenia is a major challenge for mental health service providers in Tanzania and other countries. Approximately 10% of people with schizophrenia are re-admitted due to relapse at Muhimbili National Hospital (MNH) Psychiatric Unit each month. Relapse brings about negative effects and it results in a huge burden to patients, their families, the mental health sector and the country's economy. So far no study has been done to address relapse in Tanzania. The purpose of the study was to explore perspectives on risk and protective factors influencing relapse of people with schizophrenia and their caregivers attending Muhimbili National Hospital Psychiatric Out-patient Department, Dar es Salaam, Tanzania.

METHODS

A qualitative study was conducted, involving in-depth interviews of seven people with schizophrenia who are out-patients and their seven family caregivers at MNH. Purposive sampling procedure was used to select participants for the study. Audio recorded in-depth interviews in Swahili language were conducted with all study participants. The recorded information was transcribed and analyzed using NVivo 9 computer assisted qualitative data analysis software.

RESULTS

Personal risk and protective factors for relapse, environmental risk and protective factors for relapse and suggestions to reduce relapse were the main themes that emerged from this study. People with schizophrenia and their caregivers (all of whom were relatives) perceived non adherence to antipsychotic medication as a leading risk factor of relapse; other risks included poor family support, stressful life events and substance use. Family support, adherence to antipsychotic medication, employment and religion were viewed as protective factors. Participants suggested strengthening mental health psycho-education sessions and community home visits conducted by mental health nurses to help reduce relapse. Other suggestions included strengthening the nurse-patient therapeutic relationship in provision of mental health care.

CONCLUSIONS

This study calls for improvement in mental health care service delivery to individuals with schizophrenia. Establishing a curricular in mental health nursing that aims to produce competent mental health nurse force would improve nursing practice in mental health care service delivery.

Does psychoeducation influence carers' attitudes to treatment of schizophrenia?

Objective: To measure the impact of a six-week Carer Psychoeducation Program (CPP) on factors that influence attitudes towards treatment among carers and relatives of people suffering from schizophrenia. We also examined which specific attitudes to treatment the CPP had the most effect on.

Method: Between 2002 and 2004, all patients and their relatives continued standard care. During this period, we conducted a historically-controlled open trial, in which 64 relatives completed a 17-item adapted version of the Drug Attitudes Inventory (DAI) before and after the CPP.

Results: Attitudes to treatment improved significantly overall (p < 0.001), an improvement most marked in terms of attitudes to health and illness, attitudes towards the physician and attitudes towards the potentially harmful effects of treatment. No statistically significant improvement was found, however, in attitudes to locus of control or the preventative role of treatment.

Conclusion: A CPP specifically improves family attitudes towards treatment. This finding is clinically important because such attitudes influence adherence which, in turn, influences outcome. The fact that certain attitudes are influenced by the CPP, while others are not, may help to explain the mechanism through which patient outcomes improve.

Mental health literacy survey among Sri Lankan carers of patients with schizophrenia and depression

INTRODUCTION

Mental health literacy has been defined as knowledge and beliefs about mental disorders which aid their recognition, management or prevention.

AIM

Preliminary investigation on mental health literacy among Sri Lankan carers of patients with Schizophrenia and Depression.

METHOD

Cross sectional descriptive study investigated a convenience sample of 119 carers of a person with Depression or Schizophrenia attending a community clinic using vignettes adapted from an existing mental health literacy survey.

RESULTS

The Schizophrenia vignette was reported as a crisis by 28% and 35.6% reported the Depression vignette as a crisis. Schizophrenia and Depression were identified as mental illnesses by 72% and 64% respectively. Persons with Schizophrenia and Depression were reported to be more violent than a member of the community by 61% and 60%. Psychiatrist's help was preferred as the therapeutic intervention in Schizophrenia (86.7%) and Depression (91.5%), whereas only 21.7% preferred traditional healers. Carers of persons with Schizophrenia (72%) and Depression (61%) held the attitude that the problem is a sign of personal weakness. Sixteen percent of carers wanted to avoid people with similar problems.

DISCUSSION

Carers had stigmatising attitudes such as persons with mental illness were violent and the illness was a sign of personal weakness. A minority wanted to avoid persons with similar problems, indicating that maintaining social distance was not a major issue. Carers had good knowledge of help seeking locations with a majority identifying psychiatrists and psychiatric wards in general hospitals.

CONCLUSION

The mental health literacy amongst the carers are lacking in certain areas. They have stigmatising attitudes towards people with mental illness.

Addition of home-based cognitive retraining to treatment as usual in first episode schizophrenia patients: a randomized controlled study

OBJECTIVE

We examined the effectiveness of a 2-month-long home-based cognitive retraining program together with treatment as usual (TAU; psychoeducation and drug therapy) on neuropsychological functions, psychopathology, and global functioning in patients with first episode schizophrenia (FES) as well as on psychological health and perception of level of family distress in their caregivers.

MATERIALS AND METHODS

Forty-five FES patients were randomly assigned to either treatment group receiving home-based cognitive retraining along with TAU (n=22) or to control group receiving TAU alone (n=23). Patients and caregivers received psychoeducation. Patients and one of their caregivers were assessed for the above parameters at baseline, post-assessment (2 months) and at 6-months follow-up assessment.

RESULTS

Of the 45 patients recruited, 12 in the treatment group and 11 in the control group completed post-intervention and follow-up assessments. Addition of home-based cognitive retraining along with TAU led to significant improvement in neuropsychological functions of divided attention, concept formation and set-shifting ability, and planning. Effect sizes were large, although the sample size was small.

CONCLUSIONS

Home-based cognitive retraining program has shown promise. However, further studies examining this program on a larger cohort with rigorous design involving independent raters are suggested.

Attitudes and burden in relatives of patients with schizophrenia in a middle income country

Background

Most studies of family attitudes and burden have been conducted in developed countries. Thus it is important to test the generalizability of this research in other contexts where social conditions and extended family involvement may be different. The aim of this study was to assess the relationship between the attitudes of caregivers and the burden they experience in such a context, namely Arica, a town located in the northernmost region of Chile, close to the border with Peru and Bolivia.

Methods

We assessed attitudes towards schizophrenia (including affective, cognitive and behavioural components) and burden (including subjective distress, rejection and competence) in 41 main caregivers of patients with schizophrenia, all of whom were users of Public Mental Health Services in Arica.

Results

Attitude measures differed significantly according to socio-demographic variables, with parents (mainly mothers) exhibiting a more negative attitude towards the environment than the rest of the family (t = 4.04; p = 0.000).This was also the case for caregivers with a low educational level (t = 3.27; p < 0.003), for the oldest caregivers (r = 0.546; p = 0.000) and for those who had spent more time with the patient (r = 0.377; p = 0.015). Although attitudes had significant association with burden, their explanatory power was modest (R² = .104, F = 4,55; p = .039).

Conclusions

Similar to finding developed countries, the current study revealed a positive and significant relationship between the attitudes of caregivers and their burden. These findings emphasize the need to support the families of patients with schizophrenia in this social context.

Nonadherence in mood disorders: A formidable challenge in clinical practice

Nonadherence in mood disorders poses a significant obstacle to remission and recovery. A comprehensive approach that includes evidence-based strategies have been shown to improve adherence customized to the individual needs of the patient resulting in improved quality of life and reduced disease burden. This is further strengthened by identifying risk factors, establishing therapeutic alliances, and educating patients, families and other healthcare providers.

Telepsychiatry and carer education for schizophrenia

OBJECTIVE

Despite the scientific evidence, most families of people with schizophrenia in Europe never receive a carer education programme. We evaluated whether a carer education course delivered by telepsychiatry was as effective as a carer education course delivered in situ.

METHOD

We delivered the carer education course for schizophrenia simultaneously to a carers group in rural north west Ireland (remote) via three ISDN lines and live to a carers group in a city (host). We compared knowledge gains using the Knowledge Questionnaire before and after each course.

RESULTS

Fifty-six carers of people with schizophrenia participated in the trial. At baseline, participants at the remote and host centers did not differ in terms of knowledge about schizophrenia. After the course, carers at both centers improved significantly and the knowledge gains between groups were equivalent at 6 weeks.

CONCLUSION

Telepsychiatry can deliver effective carer education programmes about schizophrenia and may provide one solution to bridging the chasm between scientific evidence and clinical reality.

Involuntary admission from the patients' perspective

BACKGROUND

Involuntary admission legislation and rates differ greatly throughout the European Union Member States. In Ireland, the Mental Health Act 2001 has introduced significant changes in the care for patients admitted involuntarily, including mental health tribunals that review the involuntary admission orders.

AIMS

To investigate (1) people's perception of the involuntary admission, (2) awareness of legal rights and perception of tribunal, (3) the impact of being admitted involuntarily on the relationship with their family, consultant psychiatrist and prospects for future employment.

METHODS

Over a 15-month period patients admitted involuntarily to a Dublin Hospital were interviewed using a semi structured interview.

RESULTS

Eighty-one people participated in the study. Seventy-two percent of patients believed that their involuntary admission was necessary at the time and this was associated with greater insight into illness. A total of 77.8% of patients felt that the treatment they received had been beneficial. A total of 86.4% of patients were aware that they had been admitted involuntarily and 45.5% of patients found it easier to accept that they had been admitted involuntarily as their case was reviewed by a tribunal. A total of 27.5% experienced a negative impact upon the relationship with their family as a result of the involuntary admission, while for 15% there was a positive impact. For 26.6% of patients the doctor-patient relationship was negatively impacted upon and a third felt their prospects for employment could be affected.

CONCLUSION

The majority of patients reflect positively on their involuntary admission and this opportunity should be used to engage patients in follow-up treatment.

Reducing the revolving door phenomenon

OBJECTIVES

De-institutionalisation and the expansion of community services have resulted in a reduction in the number of inpatient admissions in Ireland having fallen by 31% between 1986 and 2006. However, despite this, readmissions continue to account for over 70% of all admissions. The policy document A Vision for Change identified many shortcomings in the current model of provision of mental health services, making recommendations for the future development of community-based services with emphasis on outreach components such as homecare, crisis intervention and assertive outreach approaches. These recommendations are reviewed in relation to readmissions and the impact they may have on reducing the revolving door phenomenon.

METHOD

Three main intervention programmes essential to the delivery of an effective community-based service outlined and recommended by A Vision for Change, along with other pertinent factors, are discussed in relation to how they might reduce readmissions in Ireland. A series of Pearson correlations between Irish inpatient admissions rates and rates of outpatient attendances and provision of community mental health services are carried out and examined to explain possible relationships between increasing/decreasing admission rates and provision/attendances at community services. International literature is reviewed to determine the effectiveness of these intervention programmes in reducing admissions and readmissions and their relevance to the Irish situation is discussed.

CONCLUSIONS

Whilst A Vision for Change goes a long way towards advocating a more person-centred, recovery oriented and integrated model of service delivery, it is apparent from the consistently high proportion of readmissions in Ireland that there are still many shortcomings in service provision. The availability of specialised community-based programmes of care is as yet relatively uncommon in Ireland and uneven in geographical distribution. A considerable improvement in their provision, quantitatively and qualitatively, is required to impact on the revolving door phenomenon. In addition a re-configuration of existing catchment populations is required if they are to be successfully introduced and expanded.

Adherence according to Mary Poppins: strategies to make the medicine go down

PURPOSE

This article reviews the prevalence, risk factors, and burden of nonadherence in mood and psychotic disorders, and presents evidence-based, disease-specific strategies shown to improve adherence.

CONCLUSION

A comprehensive approach based on the goal of remission, designed around the patient's individual needs, facilitates adherence, leads to improved quality of life, and reduces disease burden.

PRACTICE IMPLICATIONS

Adherence in mood and psychotic disorders can be improved when providers take time to build trusting relationships; identify risk factors; anticipate nonadherence; individualize treatment; and educate patients, families, and other healthcare providers.

Addressing the needs of carers during early psychosis

AIM

To review the role and needs of family members and carers during early psychosis.

METHODS

A selective literature review was conducted.

RESULTS

Carers of persons with schizophrenia are undeniably a highly valuable source of practical and emotional support for the person affected by the illness. The role of the carer can begin even before diagnosis, with family members helping bring the patient to the attention of medical services. The diagnosis itself can be a very difficult time for carers, with family members frequently experiencing stress, anxiety, guilt, depression and feelings of loss. Furthermore, family members themselves can feel the effects of stigmatization of mental illness. The aims of family interventions during early psychosis were therefore twofold: to reduce the level of distress experienced by carers and to assist them in their role in supporting patients towards remission and recovery. A number of recent studies support a role for family interventions in early psychosis. Despite their important role, carers frequently feel undervalued and unengaged by the health-care system. Carers value good communication, and the provision of adequate information about the illness, its treatment and accessing health-care services are key priorities.

CONCLUSIONS

Carers for people affected by schizophrenia often feel undervalued. During early psychosis, interventions aimed at the family can facilitate patient identification, improve the emotional well-being of family members and support carers in their unquestionably important role in promoting remission and recovery.

Satisfied carers of persons with enduring mental illness: who and why?

BACKGROUND

This secondary mixed-methods analysis was based on the interview data collected for an exploratory study of the experiences and needs of carers of persons with enduring mental illness. The aims were to identify and describe socio-demographic and contextual factors associated with the satisfaction of carers with family support.

METHOD

Content analysis and non-parametric tests were used for the exploration of qualitative and quantitative data collected from 38 carers.

RESULTS

The majority of the satisfied carers were male and from a higher socio-economic group than other carers. The ill relatives of all satisfied participants resided outside their family homes. Carer satisfaction was associated with such categories as: a caring service; supportive and unintrusive family relationships; being accepted as partners; supportive community; and suitable family services. All the identified categories were interrelated.

CONCLUSIONS

The identified categories and socio-demographic factors should be considered for inclusion in the planning and evaluation of family support services.

Developing a risk-model of time to first-relapse for children and adolescents with a psychotic disorder

Individuals treated for psychotic disorders and mood disorders with psychotic features have a high likelihood of relapse across the life course. This study examines the relapse rate and its associated predictors for children and adolescents experiencing a first-episode and develops a statistical risk-model for prediction of time to first-relapse. A multiyear, retrospective cohort design was used to track youth, under the age of 18 years, who experienced a first-episode of psychosis, and were admitted to 1 of 6 inpatient hospital psychiatric units (N = 87). Participants were followed for at least 2 years (M = 3.9, SD = 1.3) using survival analysis. Approximately 60% of subjects experienced relapse requiring hospital readmission by the end of follow-up, with 33% readmitted within the first year and 44% within 2 years. Median survival time was 34 months. Cox proportional hazards regression identified 4 key risk factors for relapse: medication nonadherence, female gender, receiving clinical treatment, and a decline in social support before first admission.

Coping strategies and styles of family carers of persons with enduring mental illness: a mixed methods analysis

A qualitative exploratory study investigated the experiences and needs of family carers of persons with enduring mental illness in Ireland. The current mixed-methods secondary study used content analysis and statistical procedures to identify and explore the coping strategies emerging from the original interviews. The majority of family carers reported use of active behavioural coping strategies, sometimes combined with active cognitive or avoidance strategies. The percentage of cares reporting use of active cognitive strategies was the lowest among those whose ill relative lived in their home, and the highest among those whose relative lived independently. Participants with identified active cognitive strategies often reported that their relative was employed or in training. Participants who reported use of avoidance strategies were significantly younger than participants who did not report use of such strategies. The lowest percentage of avoidance strategies was among participants whose ill relative lived independently, whereas the highest was among carers whose relative lived in their home. The findings of this study highlight the importance of a contextual approach to studying coping styles and processes. Further research questions and methodological implications are discussed.

A little knowledge: caregiver burden in schizophrenia in Malawi

OBJECTIVE

To determine the relationship between schizophrenia knowledge and burden of care among caregivers of people with schizophrenia in Mzuzu, Malawi.

METHOD

We recruited 90 patients and 90 caregivers to a randomized, controlled trial of group caregiver education in schizophrenia. At baseline, we administered the Family Questionnaire, which measures caregivers' knowledge of biomedical and psychosocial aspects of schizophrenia. We measured caregiver burden with the Involvement Evaluation Questionnaire. Using multivariate analysis, we examined the relationship between knowledge and burden, controlling for other patient and caregiver variables. We hypothesised that knowledge and burden would be inversely related.

RESULTS

Caregiver burden was associated with knowledge (p = 0.001), but contrary to our hypothesis, greater knowledge was associated with greater burden.

CONCLUSION

In this population, knowledge about schizophrenia was associated with higher caregiver burden. This does not prove that knowledge causes burden, but suggests that cultural factors may mediate the relationship between knowledge and burden, and that care is needed when introducing caregiver education in new cultures.

Residential program for long-term hospitalized persons with mental illness in Japan: Randomized controlled trial

Research on the merits of long-term group residences is inconclusive. The purpose of the present paper was to investigate the effects of supported group residence on the symptoms, social function, quality of life, general health quality, and the medical/psychiatric cost in Japan of a large number of psychiatric beds and long average length of stay. Patients were assessed every 6 months for 2 years using Positive and Negative Syndrome Scale, Katz Adjustment Scale, World Health Organization Quality of Life (WHO-QOL) and General Health Questionnaire 12-item version. Patients discharged to the supported group residence (SGR) significantly improved with regard to positive symptoms, the level of socially expected activities and free-time activities. The QOL physical domain of the inpatients was significantly more deteriorated compared to the SGR group. The total psychiatric/medical cost of the SGR group was approximately one-third that of the inpatient group, while the cost of the SGR to treat physical comorbidity was much higher. The present findings indicate that SGR has advantages for mental and social function but not for physical health. A major limitation of the present study was the high mean age (>60 years) of the subjects who had been hospitalized for a long period (mean, 24 years).

Assessing knowledge of schizophrenia: development and psychometric properties of a brief, multiple-choice knowledge test for use across various samples

Psychosocial research on schizophrenia would benefit from reliable and valid measures of knowledge about schizophrenia. Although a variety of instruments have been developed to assess the effects of specific family psychoeducational programs, little research has been conducted on the psychometric properties of scales measuring knowledge about schizophrenia. This study assessed reliability and validity of a brief, easily administered, multiple-choice knowledge test completed by 441 participants from several samples: 144 lay community members, 77 family members of inpatients with schizophrenia, 170 police officers involved in a training program on mental illnesses, and 50 mental health professionals. After item analysis, good internal consistency reliability and construct validity were demonstrated for an 18-item version of this test. The findings demonstrate that knowledge about schizophrenia - a construct with potentially broad applicability in psychosocially oriented schizophrenia research - can be assessed with brief, self-administered, multiple-choice knowledge tests.

Caregiver psychoeducation for schizophrenia: is gender important?

INTRODUCTION

Females care for individuals with chronic illness more commonly than males and have different attitudes to illness. Additionally, they experience greater burden and reduced quality of life, when compared to their male counterparts. Since knowledge has been shown to be related to burden, we sought to determine whether there were gender differences in knowledge acquisition during a six-week caregiver psychoeducation programme (CPP).

METHODS

Caregivers of people with schizophrenia completed a 23-item adapted version of the self-report Family Questionnaire (FQ) before and after the six-week CPP. Using a Generalized Linear Mixed Model, we studied the differences in proportions of correct answers before and after the programme by gender.

RESULTS

Over a 46-month study period, 115 caregivers (58% female) participated in the programme. There was an overall improvement in knowledge with an effect size of 1.12. The improvement was statistically significant (P<0.001) within each of six specific areas of knowledge. However, female caregivers gained more knowledge overall and specifically regarding signs and symptoms, recovery and especially caregiver support. Knowledge gains regarding medication were roughly equal, while male caregivers gained more knowledge about risk factors.

DISCUSSION

Our findings indicate that there are gender differences in the amount and type of knowledge gained during a CPP, with female caregivers showing greater knowledge acquisition than their male counterparts in most areas. Interventions designed to assist caregivers may be improved by targeting areas of knowledge specific to each gender. Such an approach might further reduce burden and improve the outcome for their relatives affected by schizophrenia.

Burden of care in families of patients with schizophrenia

BACKGROUND

Family caregivers of persons with schizophrenia and other disorders experience high levels of burden. Most studies of family burden in schizophrenia have taken place in developed countries. The current study examined family burden and its correlates in a medium income country in South America.

METHOD

Forty-one relatives of patients with schizophrenia who were attending a public mental health outpatient service in the province of Arica, Chile, were assessed on Spanish versions of the Zarit Caregiver Burden Scale.

RESULTS

All caregivers show a very high degree of burden, especially mothers, older, with low educational level, without an employment and who are taking care of younger patients.

CONCLUSIONS

As developing country, Chile has a few national social welfare and community rehabilitation programs for relatives of psychiatric patients, especially in this part of the country. This significantly influences the high level of burden experienced by these caregivers. These results suggest a close monitoring of carer's mental health and the provision of a family intervention and psycho-social support.

Practices preventing rehospitalization of individuals with schizophrenia

While psychosocial care approaches such as assertive community treatment or partial hospitalization can help prevent psychiatric inpatient stay, the ability of specific services to prevent admission is less clear (e.g., recognizing signs of impending relapse, promoting daily structure). Therefore, within 3 months of psychiatric hospital discharge, this study examined the extent to which inpatient readmission among 264 persons with schizophrenia was averted by interventions addressing medication education, symptom education, service continuity, social skills, daily living, daily structure, and family issues. After accounting for demographic characteristics in logistic regression equations, findings suggested that interventions addressing symptom education, service continuity, and daily structure were most effective in preventing inpatient stay among individuals with four or more prior hospitalizations. However, these services became statistically insignificant in preventing readmission among counterparts with fewer previous inpatient stays. While protective effects may differ among persons with varying hospitalization histories, results indicate that resource-poor outpatient centers could focus on these three interventions when care must be limited to rehospitalization prevention.

[A telephone hotline as an easily accessible service for questions on schizophrenia]

Public relations activities of the German Research Network on Schizophrenia (GRNS) have shown that there is a demand for more information about schizophrenia disorder. This confirms international research findings that relatives of schizophrenia patients are particularly in need of information and support. In response, the GRNS has maintained a telephone hotline since 2001. The hotline is manned by clinical experts, psychiatrists, or psychologists once a week. The telephone calls are documented in a systematic manner. From 2001 to 2003, 3,909 calls were registered. This volume exceeds the limit of the hotline's resources. The telephone hotline is mainly used by relatives of psychotic patients. Most questions relate to the symptoms of schizophrenia and pharmaceutical treatment. The need for emotional support is also a high motivational factor for dialing the hotline number. The telephone hotline seems to be a worthwhile addition to the already existing crisis telephones and should be maintained even after public funding of the network expires.

Dyadic adjustment in parents of schizophrenics

OBJECTIVE

To study the dyadic adjustment in couples with a schizophrenic offspring.

METHOD

140 married couples, 67 with children with schizophrenia, and two control groups: 41 couples without pathology and 32 couples with pathology, were assessed with the Dyadic Adjustment Scale, the Beck Depression Inventory and the Self-Rating Anxiety Scale.

RESULTS

The couples with a schizophrenic offspring evidenced significantly worse dyadic adjustment than did the normal controls, especially low consensus and cohesion in husbands, and low cohesion and satisfaction in wives. Anxiety and depression in mothers of schizophrenics is significantly higher than in mothers of controls.

DISCUSSION

These findings suggest that the poor dyadic adjustment of the parents with a schizophrenic offspring could be an effect of the burden.

CONCLUSION

The treatment on the schizophrenia should be supplemented by interventions aimed at parents' dyadic adjustment, and mothers' anxiety and depression, so that they can be in better conditions to help their child.