Deliverability of psychoeducational family management

Prevalence of perceived stigma and associated factors among primary caregivers of children and adolescents with mental illness, Addis Ababa, Ethiopia: Cross-sectional study

Background

Mental illness exposes persons to stigma and this stigma also affects family caregivers of persons with mental illness. The objective of the study was to assess the prevalence of perceived stigma and associated factors among primary caregivers of children and adolescents with mental illness, Addis Ababa, Ethiopia.

Methods

A cross-sectional study design and systematic random sampling technique were used to recruit 408 participants at St. Paul’s Hospital Millennium Medical College and Yekatit-12 Hospital Medical College, Addis Ababa, Ethiopia. We collected the data by face-to-face interview. Devaluation of Consumer Families Scale was used to measure perceived stigma. Patient Health Questionnaire-9 and Oslo-3 social support scale were the instruments used to assess the factors. Coded variables were entered into Epidata V.3.1 and exported to SPSS V.21 for analysis. Binary logistic regression was used for analysis.

Result

A total of 408 participants were interviewed, with a response rate of 96.5%. The magnitude of perceived stigma was 38.5% with 95% CI (33.6-43.1). Majority (68.6%) of the respondents were female. In the multivariate logistic regression, being mother (AOR = 2.8, 95% CI: 1.59, 4.91), absence of other caregiver (AOR = 2.0, 95% CI: 1.15, 3.49), poor social support (AOR = 3.9, 95% CI: 1.59, 6.13), and symptoms of depression (AOR = 2.9, 95% CI: 1.88, 3.65) were factors significantly associated with perceived stigma.

Conclusion

The prevalence of perceived stigma among primary caregivers of children and adolescents with mental illness was high. Being mother, absence of other caregiver, poor social support, and symptoms of depression were factors significantly associated with perceived stigma.

New challenges in family interventions for schizophrenia

This review first outlines the rationale and research base supporting the development of family interventions for schizophrenia. The over-riding principles guiding effective family interventions for schizophrenia are then presented, along with the key components (engagement, assessment, education, communication skills training and problem-solving) shared by most family programs in schizophrenia. Meta-analyses demonstrating the efficacy of family interventions in reducing relapse and rehospitalization in schizophrenia are then discussed, along with issues regarding minimal duration of effective treatment, differential benefits of single and multiple family modalities and mixed evidence for the maintenance of treatment effects after termination. The benefits of participation in family-organized, nonprofessional support and education programs are then described. Finally, three issues meriting further study are outlined.

Family intervention for schizophrenia

BACKGROUND

People with schizophrenia from families that express high levels of criticism, hostility, or over involvement, have more frequent relapses than people with similar problems from families that tend to be less expressive of emotions. Forms of psychosocial intervention, designed to reduce these levels of expressed emotions within families, are now widely used.

OBJECTIVES

To estimate the effects of family psychosocial interventions in community settings for people with schizophrenia or schizophrenia-like conditions compared with standard care.

SEARCH STRATEGY

We updated previous searches by searching the Cochrane Schizophrenia Group Trials Register (September 2008).

SELECTION CRITERIA

We selected randomised or quasi-randomised studies focusing primarily on families of people with schizophrenia or schizoaffective disorder that compared community-orientated family-based psychosocial intervention with standard care.

DATA COLLECTION AND ANALYSIS

We independently extracted data and calculated fixed-effect relative risk (RR), the 95% confidence intervals (CI) for binary data, and, where appropriate, the number needed to treat (NNT) on an intention-to-treat basis. For continuous data, we calculated mean differences (MD).

MAIN RESULTS

This 2009-10 update adds 21 additional studies, with a total of 53 randomised controlled trials included. Family intervention may decrease the frequency of relapse (n = 2981, 32 RCTs, RR 0.55 CI 0.5 to 0.6, NNT 7 CI 6 to 8), although some small but negative studies might not have been identified by the search. Family intervention may also reduce hospital admission (n = 481, 8 RCTs, RR 0.78 CI 0.6 to 1.0, NNT 8 CI 6 to 13) and encourage compliance with medication (n = 695, 10 RCTs, RR 0.60 CI 0.5 to 0.7, NNT 6 CI 5 to 9) but it does not obviously affect the tendency of individuals/families to leave care (n = 733, 10 RCTs, RR 0.74 CI 0.5 to 1.0). Family intervention also seems to improve general social impairment and the levels of expressed emotion within the family. We did not find data to suggest that family intervention either prevents or promotes suicide.

AUTHORS' CONCLUSIONS

Family intervention may reduce the number of relapse events and hospitalisations and would therefore be of interest to people with schizophrenia, clinicians and policy makers. However, the treatment effects of these trials may be overestimated due to the poor methodological quality. Further data from trials that describe the methods of randomisation, test the blindness of the study evaluators, and implement the CONSORT guidelines would enable greater confidence in these findings.

Family intervention for schizophrenia

BACKGROUND

People with schizophrenia from families that express high levels of criticism, hostility, or over involvement, have more frequent relapses than people with similar problems from families that tend to be less expressive of emotions. Forms of psychosocial intervention, designed to reduce these levels of expressed emotions within families, are now widely used.

OBJECTIVES

To estimate the effects of family psychosocial interventions in community settings for people with schizophrenia or schizophrenia-like conditions compared with standard care.

SEARCH STRATEGY

We updated previous searches by searching the Cochrane Schizophrenia Group Trials Register (September 2008).

SELECTION CRITERIA

We selected randomised or quasi-randomised studies focusing primarily on families of people with schizophrenia or schizoaffective disorder that compared community-orientated family-based psychosocial intervention with standard care.

DATA COLLECTION AND ANALYSIS

We independently extracted data and calculated fixed-effect relative risk (RR), the 95% confidence intervals (CI) for binary data, and, where appropriate, the number needed to treat (NNT) on an intention-to-treat basis. For continuous data, we calculated mean differences (MD).

MAIN RESULTS

This 2009-10 update adds 21 additional studies, with a total of 53 randomised controlled trials included. Family intervention may decrease the frequency of relapse (n = 2981, 32 RCTs, RR 0.55 CI 0.5 to 0.6, NNT 7 CI 6 to 8), although some small but negative studies might not have been identified by the search. Family intervention may also reduce hospital admission (n = 481, 8 RCTs, RR 0.78 CI 0.6 to 1.0, NNT 8 CI 6 to 13) and encourage compliance with medication (n = 695, 10 RCTs, RR 0.60 CI 0.5 to 0.7, NNT 6 CI 5 to 9) but it does not obviously affect the tendency of individuals/families to leave care (n = 733, 10 RCTs, RR 0.74 CI 0.5 to 1.0). Family intervention also seems to improve general social impairment and the levels of expressed emotion within the family. We did not find data to suggest that family intervention either prevents or promotes suicide.

AUTHORS' CONCLUSIONS

Family intervention may reduce the number of relapse events and hospitalisations and would therefore be of interest to people with schizophrenia, clinicians and policy makers. However, the treatment effects of these trials may be overestimated due to the poor methodological quality. Further data from trials that describe the methods of randomisation, test the blindness of the study evaluators, and implement the CONSORT guidelines would enable greater confidence in these findings.

The potential impact of the recovery movement on family interventions for schizophrenia: opportunities and obstacles

Many types of family interventions have been found to be effective in reducing exacerbations in schizophrenia; some also improve consumer social functioning and reduce family burden. Regardless of their origins, these interventions share a number of common features, such as showing empathy for all participants, providing knowledge about the illness, assuming a nonpathologizing stance, and teaching communication and problem-solving skills. Importantly, these family interventions have many characteristics that are consistent with the growing recovery movement in mental health in that they are community-based, emphasize achieving personally relevant goals, work on instilling hope, and focus on improving natural supports. Nevertheless, these interventions are generally reflective of older models of serious and persisting psychiatric illnesses that are grounded in a "patient being treated for a chronic illness" rather than a "consumer assuming as much responsibility as possible for his/her recovery" stance. These interventions could be made more consistent with recovery principles by (1) expanding the definition of family to include marital, parenting, and sibling relationships, (2) identifying better ways to match consumers with treatments, (3) broadening the research focus to include systems change that promotes making family members a part of the treatment team (with the consumer's consent), and (4) overcoming implementation obstacles that preclude access to effective family interventions for most consumers and their relatives.

Inanspruchnahme eines psychoedukativen Gruppenangebotes für Angehörige von Patienten mit affektiven Störungen

The relevance of family interactions in the course of affective disorders has been well described. In contrast to the situation regarding schizophrenic disorders, there are few systematic concepts for involvement of the relatives of patients with affective disorders in treatment. The goal of this study was the development and evaluation of a standardised psychoeducational treatment programme. We determined the number and characteristics of relatives accepting the offer of such a group. Relatives of almost half of 55 patients with major depression and a bipolar disorder participated in the group. Relatives of male patients were more likely to take part than relatives of female patients. Relatives of patients with a bipolar disorder were more likely to take part than relatives of patients with unipolar depression. The patients whose relatives attended the group showed a more favourable understanding of the illness and more knowledge about affective disorders, but on the other hand, felt themselves to be more strongly criticised by their relatives and had less social support than the other patients. These results emphasise the importance of differential family-focused treatment modalities in affective disorders.

A comparison of the level of functioning in chronic schizophrenia with coping and burden in caregivers

BACKGROUND

A chronic mental illness such as schizophrenia is a challenging task for caregivers especially in the current era of de-institutionalization. In India, few studies have attempted to directly determine the relationship between coping mechanisms and burden; in the West, studies have found that improved coping in family members can decrease the perceived burden.

AIM

To evaluate the burden and coping of caregivers in relation to the level of functioning in patients with chronic schizophrenia.

METHODS

The sample was 100 patients with their primary caregivers attending a Psychiatry OPD. Patients were assessed on the Global Assessment of Functioning (GAF) scale while caregivers were administered the Burden Assessment Schedule (BAS) and Mechanisms of Coping (MOC) scale.

RESULTS

Fatalism and problem-solving were the two most preferred ways of coping. Problem-focused coping, i.e. problem-solving and expressive-action decreased the burden of caregivers, while emotion-focused coping, i.e. fatalism and passivity, increased it. As the level of functioning of the patient decreased, the significance with which the coping mechanisms influenced the burden, increased. The use of problem-solving coping by caregivers showed a significant correlation with higher level of functioning in patients.

CONCLUSION

Coping mechanisms such as problem-solving can decrease the burden of illness on caregivers and may even improve the level of functioning of patients.

Family intervention for schizophrenia

BACKGROUND

It has been found that people with schizophrenia from families that express high levels of criticism, hostility, or over involvement, have more frequent relapses than people with similar problems from families that tend to be less expressive of their emotions. Psychosocial interventions designed to reduce these levels of expressed emotions within families now exist. These interventions are proposed as adjuncts rather than alternatives to drug treatments and their main purpose is to decrease the stress within the family and also the rate of relapse.

OBJECTIVES

To estimate the effects of family psychosocial interventions in community settings for the care of those with schizophrenia or schizophrenia-like conditions compared to standard care.

SEARCH STRATEGY

We updated previous searches of the Cochrane Schizophrenia Group Register (June 1998), MEDLINE (1966-1995), the Cochrane Library (Issue 2 1998), EMBASE (1981-1995) and MEDLINE (1966-1995) by searching Cochrane Schizophrenia Group Register (November 2002). References of all identified studies were searched for further trial citations and authors of trials were contacted.

SELECTION CRITERIA

Randomised or quasi-randomised studies were selected if they focused primarily on families of people with schizophrenia or schizoaffective disorder and compared community-orientated family-based psychosocial intervention of more than five sessions with standard care.

DATA COLLECTION AND ANALYSIS

Data were reliably extracted, and, where appropriate and possible, summated. Relative risk (RR) with 95% confidence intervals (CI) and number needed to treat (NNT) were estimated. The reviewers assume that people who died or dropped out had no improvement and tested the sensitivity of the final results to this assumption.

MAIN RESULTS

Family intervention may decrease the frequency of relapse (n=721, 14 RCTs, RR 0.72 CI 0.6 to 0.9, NNT 7 CI 5 to 16). These data are statistically heterogeneous, the trend over time of this finding is towards the null and some small but negative studies may not have been identified by the search. Family intervention may also encourage compliance with medication (n=369, 7 RCTs, RR 0.74 CI 0.6 to 0.9, NNT 7 CI 4 to 19) but does not obviously affect the tendency of individuals/families to drop out of care (n=327, 4 RCTs, RR attrition at 3 months 0.86 CI 0.3 to 2.1). It may improve general social impairment and the levels of expressed emotion within the family. This review provides no data to suggest that family intervention either prevents or promotes suicide.

REVIEWER'S CONCLUSIONS

Clinicians, researchers, policy makers and recipients of care cannot be confident of the effects of family intervention from the findings of this review. Further data from already completed trials could greatly inform practice and more trials are justified as long as their participants, interventions and outcomes are applicable to routine care.

The relationship between coping style and burden in the carers of relatives with schizophrenia

The development of a questionnaire to measure the coping style of people caring for a relative with schizophrenia is described. Data on the psychometric properties of this questionnaire are reported for a sample of 91 carers. It is shown that coping style is associated with carer burden and psychological distress. In particular, the coping styles 'collusion', 'criticism/coercion', 'overprotectiveness', 'emotional over-involvement' and 'resignation' were found to be associated with higher levels of carer burden, and the coping style 'warmth' was found to be associated with lower levels of carer burden.