Family work in first-onset psychosis: a literature review

Tracking Needs-Based Community and Specialized Services of Young Adults and Their Parents Before and During a First Episode of Psychosis (FEP): Highlighting Intervention Trajectories in FEP

Aim

This article aims to document 10 service trajectories of young adults (YA) and their parents, informed by healthcare professionals (HP), before and during a first episode of psychosis (FEP).

Design

Based on a crisis model perspective of the Life Course Theory (Elder; Elder and Shanahan) developed by Carpentier and White, and adapted to the current context to track community and specialized services trajectories. Thematic analysis was used to code responses to open-ended questions around the need for help and accessing services by young adults affected by a psychotic disorder, and their parents.

Setting

In collaboration with FEP clinics, setting of choice by YA and their parents.

Participants

5 YA, 12 parents, and 6 HP.

Results

10 individual service trajectories grouped into 3 distinct types of trajectories (optimal, typical, and complex) based on grouping 5 similar characteristics, highlighting service access complexity and early intervention in FEP.

Conclusion

This study is the first of its kind to examine the experiences of those who seek needs-based community and specialized services leading up to and during a FEP. Findings provide key insights related to early intervention in FEP and recommendations on improving access to such services in Quebec.

Early intervention in youth psychosis: Novel approaches to understanding change

Untreated psychosis in adolescents and young adults is associated with significant and progressive impairment. Early intervention to provide support and treatment for those at risk of psychosis is essential. Several early intervention models have been developed for those at-risk and those who are victims of a recent episode - including the Portland Identification and Early Referral model (PIER; McFarlane, 2001). This study extends previous work demonstrating a variety of positive treatment outcomes achieved by PIER in the context of a large-scale implementation across the state of Delaware. The sample included 108 youth and young adults who were either at risk for psychosis or had already experienced a first episode within the past two years. Participants received the PIER treatment model and were followed from baseline to six months after they were discharged from treatment. Researchers predicted that PIER participants would experience an increase in functioning and a decrease in positive psychosis symptoms. Change over time was examined through the lens of two analytic techniques: the Reliable Change Index (RCI) analyses and Growth Curve Modeling (GCM). Results show improvement on a number of outcomes over the course of the intervention as expected. Clinical implications, limitations, and suggestions for further research are discussed.

Family environmental factors in at-risk mental states for psychosis

The family environment represents an important psychosocial factor that impacts psychosis prognosis, but little is known about its effect on the at-risk stages of psychosis. This study presents a comprehensive review and summarizes the state of the art of study on the wide range of family factors related to family functioning in the At-Risk Mental State (ARMS) for psychosis, as well as family interventions in ARMS individuals. Publications were retrieved by an extensive search on MEDLINE, PsycINFO and SCOPUS (1990-2020). Expressed Emotion is the most studied variable in ARMS literature, but there is scarce evidence of the role of other significant family factors at the ARMS stage. Overall, high Expressed Emotion did not appear to be reactive to ARMS patients' poor clinical status. However, initial evidence has suggested that relatives' beliefs about the disorder may play a significant role, either as mediators of these relationships or as predictors of Expressed Emotion. Available literature yet to yield a consistent pattern of findings on the association between Expressed Emotion or other family functioning indicators and negative outcomes, but some longitudinal studies highlight the greater potential for the protective effects of positive family environments at the ARMS stage. Family-based interventions have demonstrated benefits for both ARMS individuals and family dynamics. An increased focus on the impact of the at-risk stage of illness on relatives' mental well-being is required to provide family support based on their needs and to clarify the mechanisms leading to dysfunctional family dynamics during the critical ARMS period.

Patients' and caregivers' knowledge and beliefs about mental illness in mainland China: A systematic review

This review aimed to systematically investigate patients' and caregivers' knowledge and beliefs about mental illness in mainland China. A total of 48 eligible studies (N = 11 895) were retrieved from eight electronic databases. Prevalence statistics were computed for themes (eg, stress) under each construct relating to knowledge or belief about mental illness (eg, beliefs about causes). Effect size r was calculated for each correlation with an identified construct. We found that only 27.8% of patients recognized the symptoms of schizophrenia. Although 65% of caregivers declared that they knew the names of the disorders that their ill relatives had, depression (43.6%), schizophrenia (28.5%) and anxiety disorders (18.1%) had low recognition rates. Both caregivers and patients preferred psychosocial explanations of mental illness. Pharmacological interventions (eg, antipsychotics), non-specific actives (eg, "getting out and learning more"), mental health professionals (eg, psychiatrists) and informal support (eg, family) were each considered helpful for different disorders by caregivers, whereas regular contact with mental health professionals was not highly rated as helpful by patients. Additionally, while more patients knew about the effects of the medications that they were taking, more caregivers emphasized the importance of medicine adherence. Psychosocial variables (eg, family burden) demonstrated significant effects on both groups' mental health literacy. The government should invest more in supporting caregivers of people with mental disorders and monitor the implementation of mental health policies.

Effectiveness of Family Intervention for Preventing Relapse in First-Episode Psychosis Until 24 Months of Follow-up: A Systematic Review With Meta-analysis of Randomized Controlled Trials

BACKGROUND

Relapse risk during the early years of first-episode psychosis (FEP) considerably increases the risk of chronicity. The effectiveness of family intervention for psychosis (FIp) for preventing relapse after FEP remains unknown. We assessed the effectiveness of FIp until 24 months of follow-up for preventing relapse and other relapse-related outcomes in patients following FEP.

METHODS

We searched the Cochrane, PubMed, PsycINFO, and ProQuest databases in June 2018. A systematic review with meta-analysis of randomized controlled trials (RCTs), sensitivity analyses, and publication bias were performed, comparing to treatment as usual (TAU) or TAU plus other psychosocial interventions. Outcomes assessed were relapse rates, duration of hospitalization, psychotic symptoms, and functionality. Risk ratios (RRs) and (standardized) mean differences (SMD; MD) were calculated.

RESULTS

Of the 2109 records retrieved, 14 (11 RCTs) were included. Pooled results showed that FIp was effective for preventing relapse (RR = 0.42; 95% CI = 0.29 to 0.61) compared to TAU and/or other psychosocial interventions. It also proved effective when compared to TAU alone (RR = 0.36) and TAU plus other psychosocial interventions (RR = 0.48). FIp showed benefits in reducing duration of hospitalization (TAU, MD = -3.31; other interventions, MD = -4.57) and psychotic symptoms (TAU, SMD = -0.68), and increased functionality (TAU, SMD = 1.36; other interventions, SMD = 1.41).

CONCLUSIONS

These findings suggest that FIp is effective for reducing relapse rates, duration of hospitalization, and psychotic symptoms, and for increasing functionality in FEP patients up to 24 months. The study's main limitations were the inclusion of published research only; authors were not contacted for missing/additional data; and high heterogeneity regarding relapse definition was observed.

Taking parents seriously: The experiences of parents with a son or daughter in adult medium secure forensic mental health care

Adult forensic mental health services provide care and treatment to individuals with complex offending and mental health histories. However, little attention has been paid to the parents of those receiving care within them. This research explored the experiences of parents with an adult son or daughter with mental illness in a medium secure mental health unit. Transcripts from semi-structured interviews were analysed using interpretative phenomenological analysis. This led to the identification of three superordinate themes: 'Something's not right'-onset of mental distress; 'It's a terrible battle'-relating with professionals; and 'A very sad fact of life'-caring with no end in sight were identified which together contained nine subordinate themes. The onset of the mental distress was narrated as overwhelming, frightening, and confusing with experiences of violence. Services were seen as invalidating, and interactions with them characterized as a battle. Poor information and involvement were a common experience. Whilst diagnosis was a relief to some, the ongoing sense of loss and burden were clear. Staying connected and hopes for the future were also described. It is clear from this study that mental health services need to do more to engage and foster trust with parents from the outset and to offer support for this group. If secure services were to view parents as 'forensic carers', this may help improve respect and engagement between services and carers. Services and policymakers should strive to foster high-quality family involvement as part of developing social inclusion.

Working with Families Affected by Mental Distress: Stakeholders' Perceptions of Mental Health Nurses Educational Needs

Family and informal caregivers provide a substantial amount of care and support to people who experience mental health problems. The aim of this study was to explore mental health nurses', students' and service users' perceptions of the knowledge, skills and attitudes that are required by mental health nurses to work with families and carers using a qualitative methodology. Three themes emerged from the data: Knowledge of the family and how mental distress affects the family; working with the family - support and education; and valuing the role of the family. The three themes demonstrate the complexity of preparing mental health nurses to work with families and carers, and the article offers recommendations about how this might be achieved.

Family group interventions in an early psychosis program: A re-evaluation of practice after 10 years of service delivery

INTRODUCTION

The role of family in supporting service users in coping with illness and engaging in relapse prevention in early psychosis is important. Taking on this caring though is stressful and challenging, and it has been found that support and information for carers assists in their coping and reduces isolation.

AIMS

To evaluate the current utility of a psychoeducation group program in a public adult mental health service, for the families of people experiencing early psychosis.

METHODS

A purpose-designed pre- and post-intervention questionnaire was administered to quantitatively measure group participants' changes in perceptions of their understanding of mental illness and its treatment through attending the group. Additional qualitative items were used to determine other knowledge, benefits and any critical feedback.

RESULTS

The group program continues to result in highly significant improvements in family members' understanding of psychosis, recovery, medications, relapse prevention and substance co-morbidities. Additional feedback reaffirmed previous findings that family members find group peer support valuable and that this reduces isolation and the experience of stigma.

CONCLUSION

The current evaluation, conducted following 10 years of early psychosis group work, found there to be efficacy in family peer support groups and that it is important to provide family interventions in public early psychosis mental health services.

Do Family Interventions Improve Outcomes in Early Psychosis? A Systematic Review and Meta-Analysis

Family interventions for psychosis (FIp) are effective in reducing service user relapse and carer distress in people with schizophrenia-spectrum conditions. Several treatment and best practice guidelines recommend FIp for all people with schizophrenia. However, outcome findings in relation to early psychosis groups have been inconsistent. The current paper reports a systematic review and meta-analyses of articles that evaluated FIp in early psychosis with a clearly defined comparison group. A combination of electronic database searches (using PsychINFO, Medline, and CENTRAL), citation searches and hand searches of key journals and reviews was conducted. Peer-reviewed articles published in English from database inception to June 2016 were included. Methodological quality was assessed using the Effective Public Health Practice Project Quality Assessment Tool (EPHPP). Seventeen papers from 14 studies met inclusion criteria for review, the overall quality of which was moderate. Meta-analytic synthesis showed that FIp improved service user functioning and reduced the likelihood of relapse by the end of treatment. Psychotic symptoms were significantly reduced in the FIp group at follow up, but this was not evident at end of treatment. In terms of FIp target mechanisms, carers receiving FIp were more likely to shift from high to low expressed emotion and less likely to report patient focused criticism or engage in conflict communication than carers randomized to standard care. Carer burden and well-being were improved by the end of treatment but gains were not sustained at follow up. FIp had no impact on carer emotional over-involvement. The findings indicate that FIp is an effective intervention for early psychosis service users and their relatives. However, further research is required to establish which key therapeutic components of FIp are most effective for whom, in addition to understanding the mechanisms by which FIp might affect positive change.

Comparison of Caregiver Burden in First Episode Versus Chronic Psychosis

The aim of this study was to compare burden on caregivers of patients with first episode psychosis and caregivers of those with chronic psychosis. The study sample consisted of 39 caregivers of patients with first episode psychosis and 40 caregivers of patients with chronic psychosis. The Caregiver Burden Inventory (CBI) was used for data collection. The average caregiver burden in caregivers of patients with chronic psychosis was significantly higher than that in caregivers of patients with first episode psychosis. With regard to the subscales of CBI, there was a significantly higher level of burden in terms of time dependence, development, physical burden, and social burden in caregivers of patients with chronic psychosis than in caregivers of patients with first episode psychosis, while no such difference could be detected for the emotional burden. The absence of a difference in emotional burden suggests that caregivers of first episode psychosis may be going through an intense emotional experience, placing them in a high-risk status, despite an average caregiving experience duration of 11 months. Family interventions targeting the caregivers of patients with chronic psychosis or patients with first episode psychosis should be planned in accordance with the specific needs of these caregiver groups. It is also recommended to conduct programs involving the concurrent participation of the caregivers of patients with first episode psychosis and caregivers of patients with chronic psychosis and interventional programs such as "early psychosis support" for the caregivers of patients with first episode psychosis.

The relationship between family resiliency factors and caregiver-perceived duration of untreated psychosis in persons with first-episode psychosis

Although the family has an important role in the early detection and intervention of first-episode psychosis (FEP), there are few findings reporting associations between family strengths and early treatment-seeking experiences. This study aimed to investigate, within the framework of the resiliency model of family stress, adjustment, and adaptation, the association between family coping strategies, resource management factors and duration of untreated psychosis (DUP) in Iranian families with one adult child with FEP. Hundred and seven individuals referred to three medical centers in Tehran and diagnosed with FEP participated in this study. Caregiver-perceived DUP was measured via semi-structured interviews administered to primary caregivers. They also completed two questionnaires regarding family resources of stress management and family coping strategies. Data analysis indicated that the Family Inventory of Resources of Management (FIRM) total scale score did not significantly explain the variance of caregiver-perceived DUP, but one of the FIRM subscales, the Extended Family Social Support, and the Family Crisis-Oriented Personal Evaluation scale (F-COPES) total score and one its subscales, the Acquiring Social Support, explained a significant amount of the variance of caregiver-perceived DUP. The results suggest that higher family resiliency, especially social support, facilitates the family's appropriate adaptive reaction (i.e., treatment-seeking), with the consequent decrease of DUP.

Predictors of expressed emotion, burden and quality of life in relatives of Mexican patients with psychosis

Expressed emotion, burden and quality of life of relatives received attention because of the increasing interest in predicting and preventing relapse in psychotic patients; but they have subsequently acquired interest of their own as important aspects of families' psychological well-being. The study explores whether the psychological distress and illness perception of a sample of relatives of Mexican patients with psychosis can predict their levels of expressed emotion, burden and quality of life above patients' clinical and functional status. Sixty-five patient-relative dyads were interviewed. Relatives self-reported on expressed emotion, burden, quality of life, psychological distress and illness perception. Patients' clinical and functional status was rated by an interviewer. Pearson correlations and hierarchical multiple linear regressions were used for statistical analyses. Patients' functional status and relatives' psychological distress were significantly associated with expressed emotion, burden and quality of life. Patients' clinical status and relatives' illness perception were most strongly related to expressed emotion and burden. Relatives' psychological distress and illness perception dimensions predicted both burden and quality of life, over and above patients' clinical and functional status. Results underscore the relatives' need of support to overcome their own distress and concerns about the illness, for the psychological well-being of both patients and relatives.

Patients' and family members' experiences of a psychoeducational family intervention after a first episode psychosis: a qualitative study

The objective of this study is to explore patients' and family members' experiences of the different elements of a psychoeducational family intervention. A qualitative, explorative study was performed based on digitally recorded in-depth interviews with 12 patients and 14 family members. The interview data were transcribed in a slightly modified verbatim mode and analysed using systematic text condensation. Six themes that both patients and family members experienced as important in the family intervention were identified: alliance, support, anxiety and tension, knowledge and learning, time, and structure. A good relationship between the group leaders and participants was essential in preventing dropout. Meeting with other people in the same situation reduced feelings of shame and increased hope for the future. Hearing real life stories was experienced as being more important for gaining new knowledge about psychosis than lectures and workshops. However, many patients experienced anxiety and tension during the meetings. The group format could be demanding for patients immediately after a psychotic episode and for those still struggling with distressing psychotic symptoms. Group leaders need to recognise patients' levels of anxiety before, and during, the intervention, and consider the different needs of patients and family members in regards to when the intervention starts, the group format, and the patients' level of psychotic symptoms. The findings in the present study may help to tailor family work to better meet the needs of both patients and family members.

Comparison of psychosocial determinants in inpatients with first-episode and chronic schizophrenia in china

This study aimed at comparing psychosocial factors in inpatients with first-episode and chronic schizophrenia in China. A sample of 197 first-episode schizophrenia inpatients was compared with 392 chronic schizophrenics using Positive and Negative Syndrome Scale, Social Support Rating Scale and Childhood Traumatic Questionnaire. Our findings showed that chronic schizophrenic patients had significant higher negative symptoms but lower on positive symptoms. They were also less likely to receive social support. Our results provide understanding on the existing differences between first-episode and chronic schizophrenia. Therefore, comprehensive nursing interventions are needed to facilitate social support and medication adherence in order to prevent relapses.

Effects of Family Psychoeducation on Expressed Emotion and Burden of Care in First-Episode Psychosis: A Prospective Observational Study

The present study aimed to examine the levels and interactions of family burden (FB) and expressed emotion (EE) in first episode psychosis (FEP) patients and, secondly, to observe the potential change after a brief psychoeducational group intervention implemented in a real world clinical setting. Twenty-three key relatives of FEP patients received a brief psychoeducational group intervention. FB and EE were assessed before and after the intervention. EE-change and correlations between variables were examined. Half of the sample of key-relatives showed high levels of EE. No severe family burden was observed. FB and EE did not change after the intervention. Family subjective and objective burden were correlated with emotional overinvolvement, but not with criticism. Brief psychoeducational groups may not be sufficient to reduce FB and EE associated to the experience of caregiving for a family member with a first-episode psychotic disorder.

Course, outcomes, and psychosocial interventions for first-episode mania

OBJECTIVES

The course of bipolar disorder tends to worsen over time, highlighting the importance of early intervention. Despite the recognized need for adjunctive psychosocial treatments in first-episode mania, very few studies have evaluated psychological interventions for this period of significant risk. In this empirical review, we evaluate existing research on first-episode bipolar disorder, compare this body of research to parallel studies of first-episode schizophrenia, and identify strategies for future research.

METHODS

A comprehensive literature search of the MEDLINE and PsychINFO databases was conducted to identify studies of first-episode mania, as well as first-episode schizophrenia. Recovery and relapse rates were compared across studies.

RESULTS

In contrast to a number of studies of first-episode schizophrenia, the authors identified only seven independent programs assessing first-episode mania. Findings from these studies suggest that, while pharmacological treatment helps patients achieve recovery from acute episodes, it fails to bring patients to sustained remission. Early psychosocial intervention may be imperative in reducing residual symptoms, preventing recurrence of mood episodes, and improving psychosocial functioning. However, very few studies of psychosocial interventions for first-episode mania have been systematically studied.

CONCLUSIONS

Studies of first-episode mania indicate a gap between syndromal/symptomatic and functional recovery. Novel psychosocial interventions for first-episode mania may help bridge this gap, but require controlled study.

Treatment Response in First-episode Schizophrenia

First episode schizophrenia (FES) patients tend to be more responsive to treatment. An adequate response has been associated with a favourable long-term course in FES patients. Yet, despite the generally very favourable response profile around one quarter of the patients shows persisting symptoms of psychosis. To improve the outcome and course of psychosis great effort has emerged in identifying biological and clinical variables associated with non-response in order to identify non-responders as early as possible and adopt specific treatment strategies improving illness outcome. Different antipsychotic treatment regimens have been evaluated in terms of their efficacy in reducing symptoms of FES with psychological interventions gaining increasing importance in the treatment concept of patients suffering from their first illness episode. Therefore, aim of this review is to summarize current evidence on the response patterns, the most important predictors of response/non-response as well as on effective treatment interventions in FES patients.

Shared decision making in mental health treatment: qualitative findings from stakeholder focus groups

PURPOSE

This article reports on findings from seven stakeholder focus groups conducted in exploring shared decision making (SDM) between provider and consumer in mental health (MH) treatment in public MH.

BASIC PROCEDURES

Seven focus groups were conducted with stakeholders-consumers, family members, prescribers, MH clinicians, and rural providers. Each of the focus groups was recorded digitally, transcribed into text, and analyzed qualitatively for recurring themes.

MAIN FINDINGS

Provider barriers to SDM include history of the medical model, MH crises, lack of system support, and time. Consumer-related barriers included consumer competency, fears, insight, literacy, and trauma from past experiences. Information-exchange issues include consumer passivity, whether consumers could be viewed as experts, and importance of adequate history information. New skills needed to practice SDM included provider's knowledge about alternative treatments, mastery of person-first language, and listening skills; consumer's ability to articulate their expert information; and computer skills for both providers and consumers. Outcomes expected from practice of SDM include greater sharing of power between provider and consumer, greater follow-through with treatment plans, greater self-management on the part of consumers, and improved therapeutic alliances.

PRINCIPAL CONCLUSIONS

Implementing SDM in public MH will impact consumers and their families, providers, prescribers, and administrators. More SDM trials in public MH are needed to answer some of the many questions that remain.

The importance of consumer perceived criticism on clinical outcomes for outpatient African Americans with schizophrenia

This is the second of two studies that tests the impact of family factors on consumer functioning. This study tests the impact of the consumer's perception of being criticized by the family (consumer perceived criticism) on the consumer's clinical functioning. It likewise, concurrently tests the impact that other family factors have on perceived criticism. The sample was ninety-three consumer-family dyads. Results showed that none of the family factors directly contributed to level of perceived criticism, but more consumer perceived criticism was significantly related to higher levels of psychiatric symptoms. The findings suggest that an important component of treatment for symptom stabilization for African American consumers involves perceptions of the family being critical toward the consumer. The finding confirms for a sample of poor outpatient African American consumers what was found in previous research with African Americans. Results are in marked contrast to what impacted consumer psychosocial functioning in the companion study, suggesting that clinical and psychosocial functioning domains are distinct, particularly for African American consumers. This should be reflected in the interventions that are developed for African American consumers and their families.

Family interventions in early psychosis: specificity and effectiveness

The first episode of psychosis frequently occurs during adolescence and early adulthood, and is associated with high levels of trauma, affective disturbance and suicide. The social networks of service users often decrease significantly following the first onset, although many will remain in close contact with some family members particularly during the early phases. However, the negative impact of psychosis on families and their relationship with the identified service user are well documented. Family intervention is a recommended and evidence-based treatment in later psychosis. In this paper, we review the literature on family interventions in early psychosis in the context of new evidence for its efficacy and its routine incorporation in early intervention services for psychosis.

Family Therapy for Schizophrenia in the South African Context: Challenges and Pathways to Implementation

Schizophrenia is a chronic psychiatric disorder that affects 1% of the world's population. Family interventions whereby the patients and their relatives can attend psychiatric therapy sessions are effective at preventing relapse of symptoms. In a country such as South Africa where there has been a shift from institutionalisation to community care, family therapy treatment models are an important option to explore. Although there is a paucity of research on family therapy for schizophrenia in the South African context, we found a number of studies conducted in both developed and developing countries. Problems with adherence to medication, lack of psychoeducation and low expressed emotion (EE) were identified as challenges to effective family therapy models. A country such as South Africa has additional challenges of stigmatisation of mental illness as well as cultural perceptions of illness that may influence barriers to mental health care. These should be considered when designing family therapy interventions. We suggest further research endeavour to explore the applicability of family therapy models for people living with schizophrenia in South Africa. EE in relation to different cultural groups in South Africa should be considered.

Mental health nursing and first episode psychosis

The purpose of this literature review is to identify mental health nursing's contribution to the care and treatment of patients with a first episode of psychosis; A systematic literature review was undertaken, with 27 articles selected for study. Five domains were identified: development of therapeutic relation, relapse prevention, enhancement of social functioning, stimulation of medication adherence, and support of family members. The level of evidence of mental health nursing's contribution to the care and treatment of those undergoing their first episode of psychosis was low. Our review suggests that mental health nurses should reflect upon their own daily practices within the five domains.

Are multi family groups appropriate for patients with first episode psychosis? A 5-year naturalistic follow-up study

OBJECTIVE

To compare outcome over 5 years for patients who participated in multi family groups (MFGs) to those who refused or were not offered participation.

METHOD

Of 301 first episode psychotic patients aged 15-65 years, 147 participated in MFGs. Outcome was measured by drop-out rates, positive and negative syndrome scale (PANSS) symptom scores, and duration of psychotic episodes during the follow-up period.

RESULTS

Multi family group participants had a significantly lower drop-out rates at 5-year follow-up than patients who did not participate. However, the MFG participants had significantly less improvement in PANSS positive and excitative symptoms and had significantly longer duration of psychotic symptoms during the follow-up period.

CONCLUSION

Multi family groups appear to increase the chance of retaining patients in a follow-up study, but adjustment of the programme may be necessary with first episode psychosis patients to meet their needs better.

Effect of antipsychotic medication alone vs combined with psychosocial intervention on outcomes of early-stage schizophrenia: A randomized, 1-year study

CONTEXT

Antipsychotic drugs are limited in their ability to improve the overall outcome of schizophrenia. Adding psychosocial treatment may produce greater improvement in functional outcome than does medication treatment alone.

OBJECTIVE

To evaluate the effectiveness of antipsychotic medication alone vs combined with psychosocial intervention on outcomes of early-stage schizophrenia.

DESIGN

Randomized controlled trial.

SETTING

Ten clinical sites in China.

PARTICIPANTS

Clinical sample of 1268 patients with early-stage schizophrenia treated from January 1, 2005, through October 31, 2007. Intervention Patients were randomly assigned to receive antipsychotic medication treatment only or antipsychotic medication plus 12 months of psychosocial intervention consisting of psychoeducation, family intervention, skills training, and cognitive behavior therapy administered during 48 group sessions.

MAIN OUTCOME MEASURES

The rate of treatment discontinuation or change due to any cause, relapse or remission, and assessments of insight, treatment adherence, quality of life, and social functioning.

RESULTS

The rates of treatment discontinuation or change due to any cause were 32.8% in the combined treatment group and 46.8% in the medication-alone group. Comparisons with medication treatment alone showed lower risk of any-cause discontinuation with combined treatment (hazard ratio, 0.62; 95% confidence interval, 0.52-0.74; P < .001) and lower risk of relapse with combined treatment (0.57; 0.44-0.74; P < .001). The combined treatment group exhibited greater improvement in insight (P < .001), social functioning (P = .002), activities of daily living (P < .001), and 4 domains of quality of life as measured by the Medical Outcomes Study 36-Item Short Form Health Survey (all P < or = .02). Furthermore, a significantly higher proportion of patients receiving combined treatment obtained employment or accessed education (P = .001).

CONCLUSION

Compared with those receiving medication only, patients with early-stage schizophrenia receiving medication and psychosocial intervention have a lower rate of treatment discontinuation or change, a lower risk of relapse, and improved insight, quality of life, and social functioning.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00654576.

The efficacy of a cognitively orientated carers group in an early intervention in psychosis service--a pilot study

A significant amount of evidence has demonstrated that families and carers play an important role in an individual's recovery from a first episode of psychosis (FEP) and can significantly reduce relapse rates. This, in addition to the fact that caring for an individual experiencing their FEP can be incredibly stressful, suggests that the development of appropriate support for carers must be an integral part of any Early Intervention in Psychosis Service (EIPS). This study examines the efficacy of a closed structured group designed for carers of individuals experiencing their FEP based in Southampton city. A 12-session cognitively orientated group programme covering a range of areas was attended by 18 carers over a 6-month period. Following the group, a significant decrease was found in the carer's negative appraisals of the impact of psychosis, feelings of burden, depression and anxiety rates as measured by the Experience of Caregiving Inventory (ECI), Caregiver Burden Inventory (CBI), Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI). A significant positive correlation was also found between carer's negative appraisals and their anxiety and depression rates, although further research is needed to clarify the causality of this relationship.

Families' experience with seeking treatment for recent-onset psychosis

OBJECTIVE

Qualitative research methods were used to understand the experiences of families seeking treatment for young people with recent-onset psychosis; such knowledge can inform services design.

METHODS

The authors conducted open-ended interviews in 1999 through 2002 with family members of 13 patients with recent-onset nonaffective psychotic disorders in the New York metropolitan area, focusing on their experience in seeking treatment and engaging with mental health services.

RESULTS

Family members described early lack of clarity of diagnosis and obstacles to obtaining treatment. Entry into the mental health system frequently occurred in the context of crisis, with African-American families specifically reporting police involvement. Inpatient hospitalization was depicted as traumatic yet offering relief. Aftercare was described as fragmented, and issues with third-party payers were paramount. Families expressed a desire for more education, information, and support and described their struggles with stigma. These data from families are presented in the context of more recent literature as to the efficacy of specialized treatment programs for early stages of psychotic disorder and their involvement of families.

CONCLUSIONS

These qualitative research data support the importance of involving and educating families about psychosis: its recognition, its treatment, and access to services. They also highlight the need to address stigma and implement structural changes in treatment that ensure continuity and coverage of care. Specialized first-episode psychosis services may address these issues, and they may minimize the traumatic experiences of involuntary hospitalization and police involvement early in treatment.

Families' experience with seeking treatment for recent-onset psychosis

OBJECTIVE

Qualitative research methods were used to understand the experiences of families seeking treatment for young people with recent-onset psychosis; such knowledge can inform services design.

METHODS

The authors conducted open-ended interviews in 1999 through 2002 with family members of 13 patients with recent-onset nonaffective psychotic disorders in the New York metropolitan area, focusing on their experience in seeking treatment and engaging with mental health services.

RESULTS

Family members described early lack of clarity of diagnosis and obstacles to obtaining treatment. Entry into the mental health system frequently occurred in the context of crisis, with African-American families specifically reporting police involvement. Inpatient hospitalization was depicted as traumatic yet offering relief. Aftercare was described as fragmented, and issues with third-party payers were paramount. Families expressed a desire for more education, information, and support and described their struggles with stigma. These data from families are presented in the context of more recent literature as to the efficacy of specialized treatment programs for early stages of psychotic disorder and their involvement of families.

CONCLUSIONS

These qualitative research data support the importance of involving and educating families about psychosis: its recognition, its treatment, and access to services. They also highlight the need to address stigma and implement structural changes in treatment that ensure continuity and coverage of care. Specialized first-episode psychosis services may address these issues, and they may minimize the traumatic experiences of involuntary hospitalization and police involvement early in treatment.

The relationships among perceived criticism, family contact, and consumer clinical and psychosocial functioning for African-American consumers with schizophrenia

This study examined whether Perceived Criticism (PC) was related to community functioning in a sample of African-American consumers with schizophrenia. The study tested assumptions from the Expressed Emotion literature that were based primarily on samples of white consumers. The study found that PC affected psychiatric symptomatology but not psychosocial functioning. Greater family contact was strongly related to better psychosocial functioning. Findings suggested that the nature and impact of contact between consumer and family for this sample of African-Americans appears different from what has been found in white, middle-class samples.

Foreign-born and Swedish-born families' perceptions of psychosis care

The aim of the study was to describe how foreign-born and Swedish born families living in Sweden perceive psychosis care. Eleven foreign-born and 15 Swedish-born family members were interviewed and the data were analyzed using a phenomenographic approach. The findings showed three main descriptive categories: taking responsibility, access to care, and attitudes to psychosis. The degree of responsibility in the family decreased if there was easy access to care and support from health-care staff. Knowledge of psychosis was considered to be important in order to counteract prejudiced attitudes in the family and the community. Foreign-born families did not want to be treated differently from Swedes and stressed the importance of finding ways to communicate despite communication barriers. Foreign-born families also were affected by their experiences of psychiatric care and different beliefs about psychosis in their home country. The results indicate how important it is that health-care staff members treat families on equal terms. It is necessary to take the time to identify how to communicate in a good manner and to identify families' previous experiences of and beliefs about psychosis care in order to help families face prejudice in society and to see beyond the psychosis.

Treatment of the first episode of schizophrenia: an update on pharmacologic and psychological interventions

This review emphasizes the recent findings on different pharmacologic and psychological interventions in the treatment of first-episode schizophrenia. Most controlled studies demonstrate that first- and second-generation antipsychotics produce a similar reduction in symptom severity and an overall equal likelihood of clinical response. The cognitive improvements found across atypical antipsychotics were similar and consistent in magnitude with practice effects observed in healthy controls. However, the differential effect of low doses of haloperidol on cognitive function compared with that of second-generation antipsychotics is still debated. The different pattern of metabolic side effects induced by long-term use of antipsychotics is a crucial concern when selecting an antipsychotic treatment for a first-episode patient. More long-term studies are necessary to elucidate the metabolic effects of the different antipsychotic drugs. Cognitive-behavioral therapy and family interventions seem to be effective adjunctive treatments in early phases of schizophrenia in some patients.