The Family Questionnaire (FQ): a scale for measuring symptom appraisal in relatives of schizophrenic patients

A web-based, peer-supported self-management intervention to reduce distress in relatives of people with psychosis or bipolar disorder: the REACT RCT

BACKGROUND

Relatives caring for people with severe mental health problems find information and emotional support hard to access. Online support for self-management offers a potential solution.

OBJECTIVE

The objective was to determine the clinical effectiveness and cost-effectiveness of an online supported self-management tool for relatives: the Relatives' Education And Coping Toolkit (REACT).

DESIGN AND SETTING

This was a primarily online (UK), single-blind, randomised controlled trial, comparing REACT plus a resource directory and treatment as usual with the resource directory and treatment as usual only, by measuring user distress and other well-being measures at baseline and at 12 and 24 weeks.

PARTICIPANTS

A total of 800 relatives of people with severe mental health problems across the UK took part; relatives who were aged ≥ 16 years, were experiencing high levels of distress, had access to the internet and were actively seeking help were recruited.

INTERVENTION

REACT comprised 12 psychoeducation modules, peer support through a group forum, confidential messaging and a comprehensive resource directory of national support. Trained relatives moderated the forum and responded to messages.

MAIN OUTCOME MEASURE

The main outcome was the level of participants' distress, as measured by the General Health Questionnaire-28 items.

RESULTS

Various online and offline strategies, including social media, directed potential participants to the website. Participants were randomised to one of two arms: REACT plus the resource directory (n = 399) or the resource directory only (n = 401). Retention at 24 weeks was 75% (REACT arm, n = 292; resource directory-only arm, n = 307). The mean scores for the General Health Questionnaire-28 items reduced substantially across both arms over 24 weeks, from 40.2 (standard deviation 14.3) to 30.5 (standard deviation 15.6), with no significant difference between arms (mean difference -1.39, 95% confidence interval -3.60 to 0.83; p = 0.22). At 12 weeks, the General Health Questionnaire-28 items scores were lower in the REACT arm than in the resource directory-only arm (-2.08, 95% confidence interval -4.14 to -0.03; p = 0.027), but this finding is likely to be of limited clinical significance. Accounting for missing data, which were associated with higher distress in the REACT arm (0.33, 95% confidence interval -0.27 to 0.93; p = 0.279), in a longitudinal model, there was no significant difference between arms over 24 weeks (-0.56, 95% confidence interval -2.34 to 1.22; p = 0.51). REACT cost £142.95 per participant to design and deliver (£62.27 for delivery only), compared with £0.84 for the resource directory only. A health economic analysis of NHS, health and Personal Social Services outcomes found that REACT has higher costs (£286.77), slightly better General Health Questionnaire-28 items scores (incremental General Health Questionnaire-28 items score adjusted for baseline, age and gender: -1.152, 95% confidence interval -3.370 to 1.065) and slightly lower quality-adjusted life-year gains than the resource directory only; none of these differences was statistically significant. The median time spent online was 50.8 minutes (interquartile range 12.4-172.1 minutes) for REACT, with no significant association with outcome. Participants reported finding REACT a safe, confidential environment (96%) and reported feeling supported by the forum (89%) and the REACT supporters (86%). No serious adverse events were reported.

LIMITATIONS

The sample comprised predominantly white British females, 25% of participants were lost to follow-up and dropout in the REACT arm was not random.

CONCLUSIONS

An online self-management support toolkit with a moderated group forum is acceptable to relatives and, compared with face-to-face programmes, offers inexpensive, safe delivery of National Institute for Health and Care Excellence-recommended support to engage relatives as peers in care delivery. However, currently, REACT plus the resource directory is no more effective at reducing relatives' distress than the resource directory only.

FUTURE WORK

Further research in improving the effectiveness of online carer support interventions is required.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN72019945.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 32. See the NIHR Journals Library website for further project information.

Culturally adapted family intervention for schizophrenia in Pakistan: a feasibility study

OBJECTIVES

To establish feasibility and acceptability of a Culturally adapted Family Intervention (CulFI) that was developed using an empirically derived conceptual framework in Pakistan.

METHODS

A rater-blind, randomised trial to evaluate the feasibility and acceptability of delivering CulFI compared to treatment as usual in Karachi, Pakistan. Indicators of feasibility included evaluation of recruitment rates, retention and randomisation. We also evaluated the acceptability of the intervention and trial procedures.

RESULTS

Excellent recruitment and retention rates informed the feasibility of the intervention. CulFI had more than a 90% participant attendance of 8-10 sessions and retained more than 90% who commenced in the intervention. Eighty percent of those who initially provided consent were willing to be randomised and the quality of CulFI was rated as good to excellent by 85.7% of participants.

CONCLUSIONS

Importantly, this study determines that pathways into a psychosocial intervention can be established in Pakistan. A combination of factors contribute to low levels of access to psychiatric care including different explanatory models of illness, small numbers of trained staff, limited resources and reliance on traditional healers. These results support the feasibility, acceptability and merit of conducting a full-scale trial of CulFI in comparison with standard care.ClinicalTrials.gov Identifier: NCT02167347KEY POINTSThe significant treatment gap in LMICs leaves families providing much of the care for people with schizophrenia.There is limited evidence from LMICs supporting the effectiveness and feasibility of psychosocial interventions more broadly, and family interventions specifically.This study adds to the scarce literature and demonstrates that pathways into delivering psychosocial interventions can be established in Pakistan.The results of this trial support the feasibility and acceptability of a Culturally adapted Family Intervention (CulFI) for schizophrenia patients and their families in PakistanA full-scale trial of CulFI in comparison with standard care is warranted to determine clinical and cost-effectiveness.

Implementation of three innovative interventions in a psychiatric emergency department aimed at improving service use: a mixed-method study

Background

Emergency department (ED) use is often viewed as an indicator of health system quality. ED use for mental health (MH) reasons is increasing and costly for health systems, patients, and their families. Patients with mental disorders (MD) including substance use disorders (SUD) and suicidal behaviors are high ED users. Improving ED services for these patients and their families, and developing alternatives to ED use are thus key issues. This study aimed to: (1) describe the implementation of three innovative interventions provided by a brief intervention team, crisis center team, and family-peer support team in a Quebec psychiatric ED, including the identification of implementation barriers, and (2) evaluate the impacts of these ED innovations on MH service use and response to needs.

Method

Using mixed methods with data triangulation, the implementation and impact of the three above-named ED interventions were studied. Quantitative data were collected from 101 participants (81 patients, 20 family members) using a user questionnaire and patient medical records. Qualitative data were gathered from focus groups (n = 3) with key intervention staff members (n = 14). The user questionnaire also included open-ended questions. Descriptive, comparative and content analyses were produced.

Results

Key implementation issues were identified in relation to system, organizational and patient profiles, similar to results identified in most studies in the ED implementation literature aimed at improving responsiveness to patients with MD. Results were encouraging, as the innovations had a significant impact for improved patient MH service use and adequacy of care. Services also seemed adapted to patient profiles. Family members were grateful for the help received in the ED.

Conclusions

Before implementing innovations, managers need to recognize the basic issues common to all new healthcare interventions: the need for staff training and strong involvement, particularly among physicians, development of collaborative tools especially in cases of potential cultural clash between staff and organizations, and continuous quality assessment. Future research needs to confirm the pertinence of these interventions, especially use of family-peer support teams in ED, as a highly innovative intervention. Broader ED strategies could also be deployed to improve MH services and decrease ED use for MH reasons.

Peer Support in Mental Health: Literature Review

BACKGROUND

A growing gap has emerged between people with mental illness and health care professionals, which in recent years has been successfully closed through the adoption of peer support services (PSSs). Peer support in mental health has been variously defined in the literature and is simply known as the help and support that people with lived experience of mental illness or a learning disability can give to one another. Although PSSs date back to several centuries, it is only in the last few decades that these services have formally evolved, grown, and become an integral part of the health care system. Debates around peer support in mental health have been raised frequently in the literature. Although many authors have emphasized the utmost importance of incorporating peer support into the health care system to instill hope; to improve engagement, quality of life, self-confidence, and integrity; and to reduce the burden on the health care system, other studies suggest that there are neutral effects from integrating PSSs into health care systems, with a probable waste of resources.

OBJECTIVE

In this general review, we aimed to examine the literature, exploring the evolution, growth, types, function, generating tools, evaluation, challenges, and the effect of PSSs in the field of mental health and addiction. In addition, we aimed to describe PSSs in different, nonexhaustive contexts, as shown in the literature, that aims to draw attention to the proposed values of PSSs in such fields.

METHODS

The review was conducted through a general search of the literature on MEDLINE, Google Scholar, EMBASE, Scopus, Chemical Abstracts, and PsycINFO. Search terms included peer support, peer support in mental health, social support, peer, family support, and integrated care.

RESULTS

There is abundant literature defining and describing PSSs in different contexts as well as tracking their origins. Two main transformational concepts have been described, namely, intentional peer support and transformation from patients to peer support providers. The effects of PSSs are extensive and integrated into different fields, such as forensic PSSs, addiction, and mental health, and in different age groups and mental health condition severity. Satisfaction of and challenges to PSS integration have been clearly dependent on a number of factors and consequently impact the future prospect of this workforce.

CONCLUSIONS

There is an internationally growing trend to adopt PSSs within addiction and mental health services, and despite the ongoing challenges, large sections of the current literature support the inclusion of peer support workers in the mental health care workforce. The feasibility and maintenance of a robust PSS in health care would only be possible through collaborative efforts and ongoing support and engagement from all health care practitioners, managers, and other stakeholders.

Terminology and assessment tools of psychosis: A systematic narrative review

AIM

Phenomena within the psychosis continuum that varies in frequency/duration/intensity have been increasingly identified. Different terms describe these phenomena, however there is no standardization within the terminology. This review evaluated the definitions and assessment tools of seven terms - (i) 'psychotic experiences'; (ii) 'psychotic-like experiences'; (iii) 'psychotic-like symptoms'; (iv) 'attenuated psychotic symptoms'; (v) 'prodromal psychotic symptoms'; (vi) 'psychotic symptomatology'; and (vii) 'psychotic symptoms'.

METHODS

EMBASE, MEDLINE, and CINAHL were searched during February-March 2019. Inclusion criteria included 1989-2019, full text, human, and English. Papers with no explicit definition or assessment tool, duplicates, conference abstracts, systematic reviews, meta-analyses, or no access were excluded.

RESULTS

A total of 2238 papers were identified and of these, 627 were included. Definitions and assessment tools varied, but some trends were found. Psychotic experiences and psychotic-like experiences were transient and mild, found in the general population and those at-risk. Psychotic-like symptoms were subthreshold and among at-risk populations and non-psychotic mental disorders. Attenuated psychotic symptoms were subthreshold but associated with distress, risk, and help-seeking. Prodromal psychotic symptoms referred to the prodrome of psychotic disorders. Psychotic symptomatology included delusions and hallucinations within psychotic disorders. Psychotic symptoms was the broadest term, encompassing a range of populations but most commonly involving hallucinations, delusions, thought disorder, and disorganization.

DISCUSSION

A model for conceptualizing the required terms is proposed and future directions needed to advance this field of research are discussed.

The Paths to Negative and Positive Experiences of Informal Caregiving in Severe Mental Illness: A Study of Explanatory Models

The experience of caregiving in severe mental illness is a valuable concept for research and clinical practice as it can provide access to the idiosyncratic assessment of negative and positive dimensions of informal caregiving, thus allowing the design of interventions focused on reducing risk factors and promoting protective factors. This study was aimed at testing explanatory models of negative and positive experiences of caregiving considering the role of the caregiver’s perceptions of difficulties, satisfaction, and coping. A convenience sample of 159 informal caregivers of patients with schizophrenia was used in this study. Different variables were considered: (1) perception of difficulties (Caregiver’s Assessment of Difficulties Index); (2) perception of satisfaction (Caregiver’s Assessment of Satisfaction Index); (3) perception of coping (Caregiver’s Assessment of Managing Index); and (4) the experience of caregiving (Experience of Caregiving Inventory). Using structural equation modeling, the results revealed the following: (1) the perception of difficulties and of satisfaction coexist; (2) the negative experiences of caregiving are predominantly explained by the perception of difficulties and of coping with stress; and (3) the positive experiences of caregiving are mainly explained by the perception of sources of intrapersonal satisfaction, while the perception of coping does not have robust predictive value.

Family peer support work in an early intervention youth mental health service

This paper describes the evolution of a family peer support programme in an early intervention service in Melbourne, Australia. In response to policy directions from Federal and State governments calling for carer participation in public mental health services, and feedback from the families of young people at Orygen Youth Health, the 'Families Helping Families' project was developed. The positive acceptance by families of this innovative programme also warrants further exploration. The programme has overcome many organizational hurdles associated with specifically trained and employed family carers working alongside professional mental health clinicians. This article describes the change processes involved in implementing this programme and documents preliminary expressions of the benefits of family peer support. The contribution of lived experience in treatment and consumer care plans needs rigorous research and evaluation.

The role and experiences of family members during the rehabilitation of mentally ill offenders

Taking care of a family member with a mental illness imposes a burden on various aspects of family life. This burden may be enhanced if the mentally ill individual has a criminal history. This paper aims to summarize the scientific literature dealing with the experiences, needs and burdens of families of mentally ill offenders. We aim to explore the roles that family members play in the rehabilitation of their relative and review the families' needs and burdens. Finally, we aim to investigate whether or not the family strengths are considered in the literature. A literature search in line with the PRISMA statement for systematic reviews and with the recommendations for an integrative review was performed in the ISI Web of Science, PubMed, Elsevier Science Direct and ProQuest databases. Limited research has been carried out into the experiences, needs and burdens of families of mentally ill offenders, with only eight studies fulfilling the inclusion criteria. Families of mentally ill offenders experience more stress than those of mentally ill individuals with no judicial involvement. This is because of the fact that these family members have to deal with both mental health services and judicial systems. The eight retrieved studies focus on needs and burdens, with little reference to strengths or capabilities. The review has highlighted the need for further research into the needs and burdens of families with mentally ill offenders, with a focus on strengths rather than an exclusively problem-oriented perspective. It is important that families become more involved in the health and social care of their relatives to avoid being considered 'second patients'.

Non-pharmacological interventions for caregivers of patients with schizophrenia: A meta-analysis

It has been estimated that about 50-80% of patients with schizophrenia live with or closely contact with their caregivers, and rely on them for housing, and emotional and financial supports. Caregiving experience is usually described as stressful for their caregivers. Non-pharmacological interventions seem to be beneficial to improving life quality. However, there is still no meta-analysis focused on this topic to give an overview.We searched the electronic databases includingPubMed, EMBASE, CINAHL, Cochrane Library and China National Knowledge Infrastructure, respectively from the beginning of database to July 2015 for all the randomized controlled trialsevaluating the caregiver interventions. Continuous data were expressed mean differences (MD) with 95% confidential intervals (CIs). Standardized mean difference was planned to express, if different scales were used to measure the same outcome. We pooled the results using a random-effect model.As a result, nine studies met the inclusion criteria, comprising 608 randomized participants. In which, 321 participants were in interventional group, while 287 participants were in control group. Concerning the care burden, there was significant difference found between non-pharmacological interventions and control groups (n=290, MD -2.10, 95% CI -3.46 to -0.74, P=0.002; level of heterogeneity τ(2)=1.81, χ(2)=62.13, df=3, P<0.00001, I(2)=95%). However, no differences were found in family support, family functioning and satisfaction. Of note, our meta-analysis demonstrated the efficacy of non-pharmacological interventions for caregivers of schizophrenia, and supported the application in the clinical practice. However, all the conclusions should be explained cautiously and further confirmation is required by well-designed trials with large sample.

Motivational interviewing and interaction skills training for parents of young adults with recent-onset schizophrenia and co-occurring cannabis use: 15-month follow-up

BACKGROUND

There is a clear need for effective interventions to reduce cannabis use in patients with first-episode psychosis. This follow-up of a randomized trial examined whether an intervention for parents, based on motivational interviewing and interaction skills (Family Motivational Intervention, FMI), was more effective than routine family support (RFS) in reducing cannabis use in patients with recent-onset schizophrenia.

METHOD

In a single-blind trial with 75 patients in treatment for recent-onset schizophrenia, 97 parents were randomly assigned to either FMI or RFS. Assessments were conducted at baseline and at 3 and 15 months after the interventions had been ended. Analyses were performed on an intention-to-treat basis using mixed-effect regression models.

RESULTS

From baseline to the 15-month follow-up, there was a significantly greater reduction in FMI compared to RFS in patients' quantity (p = 0.01) and frequency (p < 0.01) of cannabis use. Patients' craving for cannabis use was also significantly lower in FMI at 15 months follow-up (p < 0.01). Both groups improved in parental distress and sense of burden; however, only FMI parents' appraisal of patients' symptoms showed further improvement at the 15-month follow-up (p < 0.05).

CONCLUSIONS

The results support the sustained effectiveness of FMI in reducing cannabis use in patients with recent-onset schizophrenia at 15 months follow-up. Findings were not consistent with regard to the long-term superiority of FMI over RFS in reducing parents' distress and sense of burden.

Towards a better understanding of caregiver distress in early psychosis: a systematic review of the psychological factors involved

OBJECTIVES

We sought to review empirical studies of psychological factors accounting for distress in caregivers of young people with early psychosis.

METHOD

Following the PRISMA guidelines, we included studies that empirically tested psychological models of caregiver distress in early psychosis by searching the following databases up until March 2014: PsycINFO, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL). This was followed by additional manual searches of reference lists and relevant journals.

RESULTS

The search identified 15 papers describing 13 studies together comprising 1056 caregivers of persons with early psychosis. The mean age of caregivers was 47.2years (SD=9.8), of whom 71.5% were female and 74.4% were parents. Nine different psychological variables were examined in the included studies, which were categorised in the following non-mutually exclusive groups: coping, appraisal/attribution and interpersonal response. There was considerable data to support the link between distress and psychological factors such as avoidant coping, appraisal and emotional over-involvement. However, the possibilities of drawing conclusions were limited by a number of methodological issues, including cross-sectional data, small sample sizes, confounding variables not being accounted for, and a wide variation in outcome measures.

DISCUSSION

The strengths of the review were the systematic approach, the exclusion of non-empirical papers and the rating of methodological quality by two independent raters. Limitations were that we excluded studies published in languages other than English, that data extraction forms were developed for this study and hence not tested for validity, and that there was a potential publication bias in favour of significant findings.

CONCLUSION AND IMPLICATIONS

A better grasp of the psychological factors accounting for caregiver distress early in the course of illness may help us understand the trajectory of distress. This is an important step in preventing long-term distress in caregivers and supporting recovery in the whole family.

Examining the cognitive model of caregiving--a structural equation modelling approach

The study tests assumptions from the "cognitive model of caregiving" (Kuipers et al., 2010), which aims to inform interventions for carers of people with psychoses. The sample comprised 61 relatives of patients with schizophrenia. Standardized psychological assessments were conducted twice within 6 months including Involvement Evaluation Questionnaire (IEQ-EU), a short form of the Symptom Checklist 90-R (SCL K9), the Family Questionnaire (FQ), scales measuring control attributions of the Illness Perception Questionnaire for Schizophrenia (IPQS-R) and emotions toward the ill relative. Structural equation modelling was used to analyse data. We identified two pathways: (a) from "attributing control to relatives" to distress, intermediated by anxiety for the patient and emotional overinvolvement (EOI), and (b) from "attribution control to patient" to distress, intermediated by anger about the patient and criticism. The model provided a good fit to the data and was successfully replicated at a second point in time. We were able to find supporting evidence for a cognitive model of caregiving. Control attributions and emotions of informal caregivers are important when interventions are planned reducing expressed emotion and burden of caregivers.

Factors associated with distress in relatives of a family member experiencing recent-onset psychosis

Factors associated with distress in relatives of people experiencing recent-onset psychosis are unclear, but subjective appraisals of the illness seem to be implicated. We aimed to identify the contribution of illness perceptions to predicting distress in relatives of people experiencing recent-onset psychosis. The relatives were assessed on measures including distress and illness perceptions, and these were repeated 6 months later. Almost half of the relatives had significant distress that persisted at 6 months. Where symptoms of the service users were more severe, and for the older relatives, distress showed less improvement. Perceptions of greater perceived future negative consequences and a more chronic timeline predicted greater distress at 6 months, whereas increased perceived coping efficacy of the relatives predicted a reduction in distress. Distress in relatives is evident early on in psychosis, but assessment of appraisals of relatives may help identify those at risk for enduring problems and offers opportunity for clinical intervention.

Feasibility of a supported self-management intervention for relatives of people with recent-onset psychosis: REACT study

BACKGROUND

Relatives of people with psychosis experience high levels of distress and require support. Family interventions have been shown to be effective in improving outcomes but are difficult to access and not suitable for all relatives.

AIMS

To assess the feasibility and effectiveness of a supported self-management package for relatives of people with recent-onset psychosis.

METHOD

A randomised controlled trial (n = 103) comparing treatment as usual (TAU) in early intervention services with TAU plus the Relatives' Education And Coping Toolkit (REACT) intervention (trial identifier: ISRCTN69299093).

RESULTS

Compared with TAU only, those receiving the additional REACT intervention showed reduced distress and increased perceived support and perceived ability to cope at 6-month follow-up.

CONCLUSIONS

The toolkit is a feasible and potentially effective intervention to improve outcomes for relatives. A larger trial is needed to reliably assess the clinical and cost-effectiveness of REACT, and its impact on longer-term outcomes.

Informal caregivers in early psychosis: evaluation of need for psychosocial intervention and unresolved grief

AIM

Relatives of service users involved with Early Intervention in Psychosis services often experience substantial distress and need associated with their role as caregivers. This study adapted versions of the relatives cardinal needs schedule and the Texas inventory of grief and tested their utility for use among relatives of service users experiencing a first episode of psychosis.

METHODS

staff, service users and relatives were consulted and a pilot took place which facilitated the creation of the relatives' urgent needs schedule-early Intervention version (RUNS-EI) and the Texas inventory of grief-early Intervention version (TIG-EI). Thirty service user-caregiver dyads were recruited for the evaluation of reliability and validity.

RESULTS

The level of 'urgent need' identified by the RUNS-EI demonstrated good concurrent validity with measures of service user social and global functioning as well as measures assessing relatives' distress, expressed emotion and grief. The measure demonstrated acceptable interrater and test-retest reliability. The profile of need is reported. The TIG-EI demonstrated 'excellent' internal consistency. It also demonstrated good concurrent validity with increased TIG-EI scores correlated with reduced service user social and global functioning as well as increased scores on measures assessing relatives' distress, expressed emotion and caregiving needs.

CONCLUSIONS

Results appear to support these assessments' utility as measures of need for psychosocial intervention and grief among relatives supporting service users experiencing a first episode of psychosis.

Carers' hope, wellbeing and attitudes regarding recovery

Carers are important to the recovery of their relatives with serious mental disorder however, it is unclear whether they are aware of, or endorse recent conceptualisations of recovery. This study compared carers' and mental health workers' recovery attitudes, and undertook multivariate predictions of carers' wellbeing, hopefulness and recovery attitudes. Participants were 82 Australian family members caring for a relative with psychosis. Carers' average recovery attitudes were less optimistic than for previously surveyed staff. Carers' recovery attitudes were predicted by perceptions that their relative's negative symptoms were more severe. Hopefulness and wellbeing was predicted by more positive and less negative caregiving experiences. Hopefulness was also predicted by less frequent contacts with their affected relative, and unexpectedly, by perceptions of more severe psychotic symptoms. Carers' wellbeing was further predicted by having a partner and having no lifetime history of a mental disorder. Hope and wellbeing are affected by everyday challenges and positive experiences of caregiving.

Motivational interviewing and interaction skills training for parents to change cannabis use in young adults with recent-onset schizophrenia: a randomized controlled trial

BACKGROUND

Cannabis use by people with schizophrenia has been found to be associated with family distress and poor clinical outcomes. Interventions to reduce drug use in this patient group have had limited efficacy. This study evaluated the effectiveness of a novel intervention for parents of young adults with recent-onset schizophrenia consisting of family-based motivational interviewing and interaction skills (Family Motivational Intervention, FMI) in comparison with routine family support (RFS).

METHOD

In a trial with 75 patients who used cannabis and received treatment for recent-onset schizophrenia, 97 parents were randomly assigned to either FMI (n=53) or RFS (n=44). Assessments were conducted at baseline and 3 months after completion of the family intervention by an investigator who remained blind throughout the study about the assignment of the parents.

RESULTS

At follow-up, patients' frequency and quantity of cannabis use was significantly more reduced in FMI than in RFS (p<0.05 and p<0.04 respectively). Patients' craving for cannabis was also significantly reduced in FMI whereas there was a small increase in RFS (p=0.01). There was no difference between FMI and RFS with regard to patients' other substance use and general level of functioning. Both groups showed significant improvements in parental distress and sense of burden.

CONCLUSIONS

Training parents in motivational interviewing and interaction skills is feasible and effective in reducing cannabis use among young adults with recent-onset schizophrenia. However, FMI was not more effective than RFS in increasing patients' general level of functioning and in reducing parents' stress and sense of burden.

The impact of a psychoeducational intervention on family members' views about schizophrenia: results from the OASIS Italian multi-centre study

BACKGROUND

The opinions of relatives of patients with schizophrenia about this disorder can influence its course and outcome.

AIMS

In 2003, the Italian Psychiatric Association promoted a study on family psychoeducational intervention to explore its effectiveness in improving relatives' opinions and beliefs about schizophrenia.

METHODS

In each of the 10 Italian mental health centres, 30 patients with schizophrenia and 30 key relatives were randomly recruited to receive the experimental intervention or the standard care. The experimental intervention consisted of 12 manual-based informative sessions on schizophrenia. Each relative filled in the self-reported questionnaire on family opinions about schizophrenia.

RESULTS

The treated sample included 107 patients and 112 relatives; the control group consisted of 105 patients and 118 relatives. In both groups, stress, traumas, heredity and family difficulties were most frequently mentioned as causing the disorder. Relatives' opinions about patients' civil rights and social competence, in particular the right to get married, to have children and to vote, improved and the belief that patients with schizophrenia are unpredictable decreased at the end of the intervention.

CONCLUSIONS

These results confirm that relatives of patients with schizophrenia should receive psychoeducational interventions, particularly in Italy where family involvement in schizophrenia care is particularly frequent.

Relatives Education And Coping Toolkit--REACT. Study protocol of a randomised controlled trial to assess the feasibility and effectiveness of a supported self management package for relatives of people with recent onset psychosis

BACKGROUND

Mental health problems commonly begin in adolescence when the majority of people are living with family. This can be a frightening time for relatives who often have little knowledge of what is happening or how to manage it. The UK National Health Service has a commitment to support relatives in order to reduce their distress, but research studies have shown that this can lead to a better outcome for service users as well. Unfortunately, many relatives do not get the kind of support they need. We aim to evaluate the feasibility, acceptability and effectiveness of providing and supporting a Relatives' Education and Coping Toolkit (REACT) for relatives of people with recent onset psychosis.

METHODS

The study is a randomised control trial. Trial Registration for Current Controlled Trials ISRCTN69299093. Relatives of people receiving treatment from the Early Intervention Service for psychosis are randomly allocated to receive either Treatment As Usual (TAU) or TAU plus the REACT intervention. The main aims of the study are to: (i) determine the acceptability of a supported self-management intervention; (ii) determine preference for type of support; (iii) assess the feasibility of the design; (iv) identify the barriers and solutions to offering support for self-management approaches within the NHS; (v) estimate the likely effect size of the impact of the intervention on outcome for relatives; (vi) gain detailed feedback about the barriers and solutions to using a self-management approach; (vii) describe the way in which the intervention is used. Outcomes will be assessed from baseline and at 6 month follow-up.

DISCUSSION

The intervention is compared to current treatment in a sample of participants highly representative of relatives in routine early intervention services across the UK. The intervention is protocolised, offered within routine practice by existing staff and extensive process data is being collected. Randomisation is independent; all assessments are made by blind raters. The limitations of the study are the lack of control over how the intervention is delivered, the short follow-up period, and the lack of assessment of service user outcomes. Despite these, the findings will inform future effectiveness trials and contribute to the growing evidence base for supported self-mangement interventions in mental health.

Coping with schizophrenia in forensic services: the needs of relatives

This study aimed to assess the needs of the relatives of patients in forensic services and to understand their concerns, perceptions, and ability to cope with the symptoms of schizophrenia. The needs of 18 relatives were assessed using the Family Questionnaire (FQ; Quinn et al., Acta Psychiatr Scand 108:290-296, 2003) and the Relatives' Cardinal Needs Schedule (RCNS; Barrowclough et al., Psychol Med 28:531-542, 1998). The FQ revealed that all symptoms were rated as "frequent." The RCNS supported the data from the FQ because the relatives displayed a need for support and information about the mental illness of schizophrenia. Antisocial behavior was rated as the highest cardinal need (83%), with negative symptoms, interpersonal behavior, psychotic symptoms, and affective symptoms also rated as cardinal needs by more than half of the relatives. The relatives have to cope with a range of symptoms and behaviors displayed by the forensic patient, which can be extremely difficult. Forensic services should provide support for families making information about antisocial behavior a priority.

Aggression and trauma experiences among carer-relatives of people with psychosis

BACKGROUND

Exposure to aggression and associated psychological outcomes are poorly characterised among carer-relatives of people with psychosis.

METHOD

Carer-relatives (N = 106) completed questionnaires assessing socio-demographics and perceived prevalence of aggression in their caring role in the last 12 months. Carers exposed to moderate-severe levels of aggression were re-approached to assess PTSD and coping strategies.

RESULTS

Most respondents (77.4%) reported experiencing moderate-severe levels of aggression. Increased contact with (M = 15.12 vs. M = 6.71 days per month), and significantly higher ratings of affective, antisocial, negative and psychotic symptomology in affected relatives were associated with experiences of moderate-severe aggression. Approximately half of the moderate-severe respondents reported potentially significant levels of PTSD (52%, N = 34), which was associated with greater exposure to verbal aggression and increased usage of coping strategies.

CONCLUSIONS

Comparable ratios of physical to non-physical aggression to those reported by professional carers working in acute psychiatric treatment settings were reported. Carer-relatives require greater levels of information and support to assist them in their community caring roles.

Predictive validity of the Family Attitude Scale in people with psychosis

Expressed Emotion (EE) strongly predicts relapse in mental disorders, but there remains a need to develop and refine brief, self-report measures. This article describes two studies testing the validity of a self-report measure of criticism or burden, the Family Attitude Scale (FAS), in relatives of patients with psychosis. Study 1 had 54 families of patients with psychosis and a substance use disorder, while Study 2 had 61 families of patients at an early psychotic episode. In Study 1, a consensus FAS was obtained; in Study 2 separate parental scores were used. The FAS was positively associated with EE, and with relationship negativity. Associations with negative caregiving experiences or stress were restricted to maternal or consensual FAS ratings. FAS scores predicted relapse in both studies, although prediction at the optimal cutoff (>or=60) only reached statistical significance in Study 2, and time to relapse was only predicted by the FAS in Study 1. Prediction of relapse from the CFI was stronger, and the FAS did not add to that prediction. Results supported the utility of the FAS, but confirmed the pre-eminence of the CFI as a household-related predictor of relapse.

Primary caregivers of schizophrenia outpatients: burden and predictor variables

This article explores family burden in relation to relatives' coping strategies and social networks, as well as in relation to the patients' severity of positive and negative symptoms. Data on the severity of symptoms (Positive and Negative Syndrome Scale for Schizophrenia [PANSS]), social functioning (Social Functioning Scale [SFS]), caregivers burden (Interview on Objective and Subjective Family Burden or Entrevista de Carga Familiar Objetiva y Subjetiva [ECFOS]), coping skills (Family Coping Questionnaire [FCQ]), and social support (Social Network Questionnaire [SNQ]) were gathered from a randomized sample of 101 Chilean outpatients and their primary caregivers, mostly mothers. Low levels of burden were typically found, with the exception of moderate levels on general concerns for the ill relative. A hierarchical regression analysis with four blocks showed that clinical characteristics, such as higher frequency of relapses, more positive symptoms and lower independence-performance, together with lower self-control attributed to the patient, decrease in social interests, and less affective support, predict burden. The results support the relevance of psychoeducational interventions where families' needs are addressed.

Assessment of need for psychosocial interventions in an Asian population of carers of patients with schizophrenia

AIM

This paper reports on a study to establish the profile of need for psychosocial family interventions and to examine the concurrent validity of the Relatives' Cardinal Needs Schedule with an Asian population of carers in England, UK.

BACKGROUND

Although psychosocial interventions for schizophrenia have a strong evidence base, little is known of the needs of Asian families. A cardinal need is indicative of the existence of a problem causing the carer a strain for which the carer is willing to co-operate if help is offered and for which systematic help has not been provided in the last 12 months.

METHODS

The Relatives' Cardinal Needs Schedule was used to assess needs in a small randomly selected sample of Asian carers in one English locality and to compare the results with independent measures of patient symptoms and carer distress.

RESULTS

Feedback from carers indicated that the Relatives' Cardinal Needs Schedule was culturally acceptable and appropriate to their needs. There was evidence for the validity of the assessment in that there were large and statistically significant associations between the number of needs detected by the Relatives' Cardinal Needs Schedule and independent measures of both carer distress (as measured by the 28 item General Health Questionnaire) and patient symptom severity (as reliably assessed from case notes).

CONCLUSION

The Relatives' Cardinal Needs Schedule may prove useful for nurses and service managers in establishing the need for psychosocial family interventions amongst Asian families in the United Kingdom.

A sociocultural stress, appraisal, and coping model of subjective burden and family attitudes toward patients with schizophrenia

A sociocultural stress, appraisal, and coping model was developed to understand relatives' burden of care and negative affective attitudes toward patients with schizophrenia. Ninety-two African American and 79 White patients and a significant other (80% mothers) completed 2 10-min family problem-solving discussions. In addition, the Kreisman Rejection Scale and a global self-report rating of family burden were administered to relatives, and a self-report rating of substance use was administered to patients. Results indicated that subjective burden of care and patients' odd and unusual thinking during the family discussion each independently predicted relatives' attitudes toward patients, suggesting that negative attitudes are based in part on both patients' symptoms and perceived burden of care. African American relatives' perceived burden was also predicted by patients' substance abuse. Finally, White family members were significantly more likely than African Americans to feel burdened by and have rejecting attitudes toward their schizophrenic relative suggesting that cultural factors play an important role in determining both perceived burden and relatives' attitudes toward patients.

Mastery, burden, and areas of concern among family caregivers of mentally ill persons

In an era of limited resources for mental health care, family interventions need to target areas where they are responsive to families' expressed needs. Although family burden has been documented, less is known about the areas of concern that families feel they need direct assistance with, to be effective caregivers. Telephone interviews were conducted with 30 family members of mentally ill relatives. Burden, sense of mastery, and contexts of caregiving were assessed. Open-ended questions elicited further understandings of caregiving concerns. The most frequently identified burden was "worry about the future." The greatest concern was "dealing with sadness and grief." Recommendations for assessing family concerns are presented.