A family psychoeducation group program for chinese people with schizophrenia in Hong Kong

A 1-Day Training Course to Disseminate the BREF Psychoeducational Program to Caregivers and Promote Network Establishment between Psychiatry Departments and Family Associations

OBJECTIVE

Although international guidelines state that psychoeducation to caregivers should be provided systematically, it remains insufficiently available in psychiatry. This study reports the development and evaluation of an original training course aimed to provide participants with the knowledge and skills to implement "BREF," a psychoeducational program for caregivers.

METHODS

The BREF program training course, a free, 1-day course incorporating peer role-play was developed. In addition to psychiatrists, nurses, and psychologists, caregivers were involved as preceptors. Participants were mental health professionals and volunteer caregivers. Participants to the first 28 sessions of the course (n=467) completed a post-course questionnaire (n=341) and a cross-sectional questionnaire (n=56). Quantitative data on satisfaction, learning, and behavior changes following the course were collected equating to levels 1, 2, and 3 of Kirkpatrick's model.

RESULTS

After the course, high levels of satisfaction and commitment were observed with 100% of responders recommending the course and 81% intending to implement the BREF program. Confidence mean score to implement BREF was 7.9/10 (±1.4) with no significant effect of course session. At cross-sectional evaluation, 73% of responders reported improvements in skills related to providing psychoeducation to caregivers, 64% stated that the BREF program was implemented/under implementation, and 66% stated that their department had connected with a family association.

CONCLUSIONS

Training course sessions alone can increase psychoeducational programs for caregivers and network establishment. The BREF program training course demonstrates a high level of participant satisfaction and is a promising method to disseminate psychoeducation to caregivers, thus addressing a major shortage in mental health organization.

Effectiveness of Psychoeducation on Burden among Family Caregivers of Adults with Schizophrenia: A Systematic Review and Meta-Analysis

Caring for relatives living with schizophrenia could lead to caregivers' burden. It is believed that lack of information and understanding about schizophrenia and lack of skills to cope effectively while caring for their adult relatives largely contribute to the burden they experience. The burden is assessed using assessment scales. This review aims to assess the effectiveness of psychoeducation in alleviating the burden experienced by family caregivers of adults living with schizophrenia and to identify essential factors that facilitate positive outcomes. Five databases (ASSIA, CINAHL, Embase, MEDLINE EBSCO, and PsycINFO) were systematically searched using combinations of the following key terms: "family caregivers," "schizophrenia," "burden," "psychoeducation," and "adults." Meta-analysis of included studies was conducted using RevMan 5.4. Five RCTs with 320 family caregivers were included in the review. Overall, none of the studies showed a low risk of bias. The evidence suggests that face-to-face group psychoeducation reduced family caregivers' burden when measured across different time points: one-week postintervention (mean difference -3.87 and Cl -6.06 to -1.70), six months (MD -8.76 and Cl -12.38 to -5.13), and twelve months (MD -7.38 and Cl -9.85 to -4.91). Measurements immediately after the intervention, one month, and three months postintervention when reported narratively also showed a reduction in family caregivers' burden. Face-to-face group psychoeducation provided for family caregivers effectively alleviates the burden they experience. Factors such as program content and teaching methods facilitated positive outcomes. It is recommended that psychoeducation should be integrated as a routine intervention for family caregivers.

The Effects of a Mindfulness-Based Family Psychoeducation Intervention for the Caregivers of Young Adults with First-Episode Psychosis: A Randomized Controlled Trial

OBJECTIVE

In this study, we investigated the effects of a mindfulness-based family psychoeducation (MBFPE) program on the mental-health outcomes of both caregivers and young adults with first-episode psychosis with an onset in the past three years through a multi-site randomized controlled trial. We also studied the outcomes of three potential mediating effects of interpersonal mindfulness, expressed emotions, and non-attachment on the program.

METHOD

We randomly assigned 65 caregivers of young adults with psychosis to MBFPE (n = 33) or an ordinary family psychoeducation (FPE) program (n = 32); among them, 18 young adults in recovery also participated in the evaluation of outcomes.

RESULTS

Intent-to-treat analyses were conducted. No significant time × group interaction effects of MBFPE and FPE programs were found in any of the caregivers' outcomes. However, the young adults with psychosis reported higher levels of recovery after the MBFPE program than after the ordinary FPE program (F = 8.268, p = 0.012, d = 1.484). They also reported a larger reduction in over-involvement of their caregivers (F = 4.846, p = 0.044, d = 1.136), showing that MBFPE had a superior effect to FPE in promoting recovery and reducing over-involvement.

CONCLUSIONS

A brief psychoeducation program may not reduce the burden on or improve the mental-health outcome of caregivers of individuals with recent-onset psychosis. However, integrating mindfulness into a conventional family psychoeducation program may reduce the expressed emotions of caregivers, especially over-involvement. Further studies should explore how psychoeducation programs can reduce the impact of psychosis on family through sustainable effects in terms of reducing their burden and expressed emotions, using a rigorous study and adequate sample size.

Multi-Family Therapy for First Episode Psychosis: Experiences of Families in Singapore

Aim: This qualitative study examined the experiences of families with Multi-Family Therapy (MFT) provided by the Early Psychosis Intervention Programme (EPIP) in Singapore. The MFT was piloted over a period of 2 years and findings from this study were used to further refine the MFT to better meet the needs of Singaporean families in the service. Methods: Families who completed the MFT were invited to participate in the study. Nine clients and ten carers who consented to participate in the study were allocated to two client and two carer Focus Group Discussions (FGDs) respectively. A semi-structured interview schedule was used to facilitate the discussions. The FGDs were audio recorded, transcribed, and anonymised. The data was analysed using thematic analysis. Results: Four main themes emerged from the analysis: (1) therapeutic processes of MFT, (2) positive changes in family relationships, (3) improvements in coping with psychosis, and (4) suggestions for improvement in MFT. The families suggested some structural changes to the MFT, and more carers than clients would prefer therapists to offer more expert advice. Conclusions: Findings suggest that a Western-based MFT can be adapted to work with Singaporean families. This study sheds light on the therapeutic processes that may be related to the changes in family relationships and coping with psychosis. In addition, it suggests that therapists taking an expert and authoritative approach may not fit with the needs of younger generations in Singapore. It advocates for therapists to take a flexible and fluid stance to work with Singaporean families.

Psychoeducation as Precision Health in Military-Related Mild Traumatic Brain Injury

A significant proportion of Service Members and Veterans (SMVs) experience at least 1 mild traumatic brain injury during military activities (mil-mTBI), which can result in enduring cognitive symptoms. Although multiple cognitive rehabilitation (CR) interventions have been developed for this population, patient psychoeducation focusing on biopsychosocial relationships and health behaviors is often cited as the first line of defense for mil-mTBI sequelae. However, theoretical and conceptual foundations of these psychoeducational techniques are not well articulated. This raises questions about the potency of attempts to boost health literacy in affected SMVs, who represent a highly heterogeneous patient population within a special cultural milieu. To elucidate the significance of this problem and identify opportunities for improvement, we view the psychoeducation of SMVs through the lens of educational principles described in serious mental illness, where "psychoeducation" was first formally defined, as well as contextual and phenomenological aspects of mil-mTBI that may complicate treatment efforts. To advance psychoeducation research and practice in mil-mTBI, we discuss how treatment theory, which seeks to link active treatment ingredients with specific therapeutic targets, and an associated conceptual framework for medical rehabilitation-the Rehabilitation Treatment Specification System-can be leveraged to personalize educational content, integrate it into multicomponent CR interventions, and evaluate its effectiveness.

Family involvement moderates the relationship between perceived recovery orientation of services and personal narratives among Chinese with schizophrenia in Hong Kong: a 1-year longitudinal investigation

PURPOSE

Family has been found to have an influential role on clinical and recovery outcomes of people with schizophrenia. While recovery-oriented services can facilitate service users to develop a rich and positive identity, it is unclear how different levels of family involvement may interact with recovery-oriented services in affecting personal recovery. The present study aimed to examine how family involvement moderates the relationship between perceived recovery-orientation of services and personal narratives of Chinese people in Hong Kong who had recent onset of schizophrenia spectrum disorder longitudinally.

METHOD

Multi-method approach (semi-structured interview, researcher ratings, self-report measures) was adopted. 167 participants completed assessments at baseline; 93 and 68 of them were retained at 6-month and 12-month follow-up assessment, respectively.

RESULTS

Baseline perceived recovery orientation of services significantly predicted richer personal narratives at 6-month follow-up when baseline family involvement was optimal (B = 0.26, p = 0.03, 95% CI [0.02-0.48]). As to 12-month assessment, baseline perceived recovery orientation of services significantly predicted poorer personal narratives when family was perceived as under-involved at baseline (B = - 0.45, p = 0.02, 95% CI [- 0.88 to - 0.07]).

CONCLUSION

Without proper family involvement, recovery-oriented services could be ineffectual in facilitating the development of rich personal narratives for Chinese people in Hong Kong.

Outside-in or Inside-out? A Randomized Controlled Trial of Two Empowerment Approaches for Family Caregivers of People with Schizophrenia

Training-based intervention such as psychoeducational groups has become increasingly popular to empower family caregivers of people with schizophrenia, yet existing supportive programs for caregivers tend to focus more on the needs of the patients rather than the development of the caregivers. This study aimed to compare the outcomes of a skill-based empowerment psychoeducational group and an inner-resource enhancing empowerment narrative therapy group for family caregivers of people with schizophrenia. We conducted a randomized controlled trial with a longitudinal design. The sample consisted of 132 family caregivers who were randomly assigned to eight sessions of the two groups (i.e. a narrative-based group, or a psychoeducational group), or a control group with delayed treatment. Psychometric scales were administrated throughout the project. Both the psychoeducational group and the narrative group showed significant improvements in family relationships, caregiving burden, and coping skills compared with the control group across the three time points (pretest, posttest, and 2-month follow-up). A statistically significant advancement in coping skills was found in the psychoeducational group. The narrative group outperformed the psychoeducational group and the control group in the enhancement of inner resources, perceived control, and level of hope. The findings call for the need of an integrative empowerment approach that both values the inner strength and unique experiences of the caregivers and at the same time provides them with necessary skills and knowledge in taking care of their family members with schizophrenia.

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.

Service evaluation of a sole-session psychoeducational intervention to improve caregivers’ key illness beliefs after first episode psychosis (FEP)

Carers of people experiencing a first episode of psychosis are at an increased risk of developing their own physical and mental health problems. Psychoeducation has been found to improve carer wellbeing and reduce distress. However, few psychoeducation interventions have considered the resource constraints on mental health services and the impact that these can have on the implementation of any such interventions. The present service evaluation aimed to evaluate an abbreviated version (sole session) of a previously tested psychoeducation intervention (three sessions) that targets less adaptive illness beliefs (n = 17). Pre–post effect sizes reveal that all of the carers’ illness beliefs changed in the desired direction, with four out of the 10 illness beliefs associated with large to moderate improvements. When compared with the outcomes obtained in our evaluation of the more intensive, three-session version of the intervention, the between-group effects largely favoured the three-session version but were mostly small. Moderate to large effects in favour of the three-session version were found for two of the 10 illness beliefs. These findings support the further investigation of the sole session psychoeducation intervention as part of a randomised controlled trial.

Key learning aims

(1)

Interventions delivered by nurses in adult outpatient psychiatric care: An integrative review

WHAT IS KNOWN ON THE SUBJECT?: In many countries, the majority of psychiatric care is being delivered in an outpatient setting and the proportion of outpatients is increasing on a global level. Nurses are the largest workforce in psychiatric care, but their role has been said to be difficult to define. According to our knowledge, there are no previous reviews focusing on nurse-delivered interventions in the adult psychiatric outpatient setting. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This review summarizes nurse-delivered interventions identified in the research literature and describes these systematically. Analysing all the identified interventions using the Nursing Interventions Classification, we conclude that the emphasis of nurse-delivered interventions in psychiatric outpatient care is on interventions aiming at improving the functioning of both patients and their family members by building on their own strengths. These findings differ from those presented in a review on inpatient psychiatric nursing. There are several clinical trials describing nurse-delivered evidence-based treatments, such as psychoeducation for patients and their family members in the case of patients diagnosed with schizophrenia and bipolar disorder. The quality of randomized controlled trials was higher than in earlier reviews describing psychiatric nursing interventions in general or in connection with a specific patient group. Further clinical trials are needed to describe the role of nurses in the care of patients diagnosed with depression and in the use of web-based interventions. Additionally, it would be important to study what supports, and on the other hand hinders, the role of nurses in delivering evidence-based treatments at the clinical level. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses can play a central role in responding to the growing demand for evidence-based practices in adult outpatient psychiatry, by delivering treatments for patients and family members. It is important that both nursing education and clinical practices recognize and support this role. Abstract Introduction According to our knowledge, there are no previous reviews on nurse-delivered interventions in the adult psychiatric outpatient setting. Aim To identify and systematically describe and analyse nurse-delivered interventions based on research literature. Method An integrative review. Results This review included 60 studies, of which 46 were intervention studies, including 40 clinical trials. The most common patient groups were patients diagnosed with schizophrenia and bipolar disorder. The nursing interventions described in the studies resembled a total of 68 interventions from the Nursing Interventions Classification. The treatment delivery methods varied and treatments often lacked a clear theoretical background. Implications for practice The core of nurse-delivered interventions identified in research literature in psychiatric outpatient care is on interventions aiming at improving the functioning of both patients and their family members by building on their own strengths. These findings differ from the interventions identified in a review describing nursing in the inpatient setting. There are high-quality clinical trials describing nurse-delivered treatments for patients diagnosed with schizophrenia and bipolar disorder. These include evidence-based treatments such as psychoeducation. Understanding of how these treatments are transferred in clinical practice is missing. Clinical trials describing nurse-delivered web-based interventions and interventions for patients diagnosed with depression are needed.

Psychoeducational Interventions for People with Schizophrenia: Findings from the Systematic Reviews

Aims: This systematic review examines the effectiveness of the psycho-educational interventions (PEIs) targeted at people diagnosed with schizophrenia and their primary caregivers on improving knowledge level of schizophrenia and health-related outcomes.Methods: A total of 28 studies were reviewed from December 1999 to May 2015. The methods described by Centre for Reviews and Dissemination were used to guide this review.Results: The PEIs showed consistent improvement in the knowledge level of schizophrenia among participants for various follow-up intervals. In addition, PEIs were found to be superior to treatment as usual in influencing health-related outcomes.Conclusions: Implications of the findings for mental health care practice and education and recommendations are discussed.

Effectiveness of an Assertive Community Treatment program for people with severe schizophrenia in mainland China - a 12-month randomized controlled trial

BACKGROUND

Assertive Community Treatment (ACT) is an evidence-based treatment program for people with severe mental illness developed in high-income countries. We report the first randomized controlled trial of ACT in mainland China.

METHODS

Sixty outpatients with schizophrenia with severe functional impairments or frequent hospitalizations were randomly assigned to ACT (n = 30) or standard community treatment (n = 30). The severity of symptoms and level of social functioning were assessed at baseline and every 3 months during the 1-year study. The primary outcome was the duration of hospital readmission. Secondary outcomes included a pre-post change in symptom severity, the rates of symptom relapse and gainful employment, social and occupational functioning, and quality of life of family caregivers.

RESULTS

Based on a modified intention-to-treat analysis, the outcomes for ACT were significantly better than those of standard community treatment. ACT patients were less likely to be readmitted [3.3% (1/30) v. 25.0% (7/28), Fisher's exact test p = 0.023], had a shorter mean readmission time [2.4 (13.3) v. 30.7 (66.9) days], were less likely to relapse [6.7% (2/30) v. 28.6% (8/28), Fisher's exact test p = 0.038], and had shorter mean time in relapse [3.5 (14.6) v. 34.4 (70.6) days]. The ACT group also had significantly longer times re-employed and greater symptomatic improvement and their caregivers experienced a greater improvement in their quality of life.

CONCLUSION

Our results show that culturally adapted ACT is both feasible and effective for individuals with severe schizophrenia in urban China. Replication studies with larger samples and longer duration of follow up are warranted.

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

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

Psychoeducational therapy with families of paranoid schizophrenia patients

AIM

The study aimed to measure the effectiveness of psychoeducational therapy on the burden of families of paranoid schizophrenia patients.

METHODS

An experimental research design was used in this study with an equivalent control group using 84 random allocation samples at a mental hospital in Semarang. The study instrument was the Indonesian version of the care burden scale (CBS). The Mann-Whitney test was used for the data analysis.

RESULTS

The findings obtained show the effectiveness of psychoeducational therapy on family burden in the experimental group as opposed to standard therapy in the control group (before: Z=-1.27; P=.092, and after: Z=-3.47; P=.002).

CONCLUSION

We conclude that family psychoeducational therapy, as given to the experiment group, can decrease the family burden for the family of a paranoid schizophrenia patient. The application of family psychoeducational therapy can serve as guidance for the psychiatric nurse in reducing the family burden in the care of patients with paranoid schizophrenia.

Evaluating the effectiveness of a culturally adapted behavioral family psycho-educational program for Egyptian patients with schizophrenia

Although a growing body of evidence supports the effectiveness of behavioral family therapies for patients with schizophrenia, few studies have been carried out on the effectiveness of such programs for Egyptian patients. The current study translated and culturally adapted the Behavioral Family Psycho-Education Program (BFPEP) and conducted a preliminary efficacy evaluation for outpatients suffering from schizophrenia. Thirty patients received 14 sessions of culturally adapted Program (CA-BFPEP) and 30 received treatment as usual; all were followed up for 6 months. Pre- and post-intervention assessment included primary outcome measures that assessed the clinical, social, quality of life and attitude towards medications. The CA-BFPEP group demonstrated significant treatment effects as they had greater reductions in psychotic symptoms (PANSS), improvement of social function (SFQ), quality of life (QoL), and attitude towards medications (DAI), compared to patients in the control group. These results demonstrate the feasibility of implementing family therapy interventions in different cultural settings with relatively minor modifications. These promising findings invite further efforts to maximize the benefits of family therapy interventions internationally and to encourage mental health policy makers to integrate this mode of therapy in routine care management plans for patients with schizophrenia.

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

Background

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

Aims

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

Design

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

Setting

Two mental health trusts in north-west England.

Participants

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

Interventions

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

Main outcome measures

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

Results

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

Limitations

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

Conclusions

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

Future work

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

Trial registration

Current Controlled Trials ISRCTN94393315.

Funding

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Using 'WeChat' online social networking in a real-world needs analysis of family members of youths at clinical high risk of psychosis

OBJECTIVE

The argument surrounding the safety and effectiveness of interventions for the population of individuals at a clinical high risk of developing psychosis has been ongoing for the past 30 years. However, few studies have assessed the needs of this special young population, who are struggling with the recent onset of psychotic symptoms.

METHOD

The sample consisted of 171 family members of 108 clinical high-risk individuals included from the ShangHai at Risk for Psychosis research programme. A 'WeChat' group was established to provide mutual support. There were 22,007 valid messages sent within the group between 1 April 2015 and 27 June 2016. Chat records were subsequently analysed to determine the needs of families during intervention at the early stages of psychosis.

RESULTS

Families of clinical high-risk individuals were highly involved in the entire medical process, and the major concerns of the families of clinical high-risk individuals focused on both functional recovery and medication. The themes of 'take medication', 'go to school' and 'study in school' were often discussed within the group.

CONCLUSION

A family-focused intervention targeting functional recovery and real-time professional explanations of medication would meet the major needs of families of Chinese clinical high-risk individuals.

Effects of Psychoeducation Given to Caregivers of People With a Diagnosis of Schizophrenia

The aim of this study was to evaluate the effectiveness of psychoeducation given to caregivers of patients diagnosed with schizophrenia on their perceptions of burden and on clinical course of patients. This was a quasi-experimental study with pre-post tests and a control group and designed as a nonrandomized controlled intervention trial. While the patients in both the intervention and the control group received treatment as usual (TAU), only the caregivers in the study group were offered two sessions of psychoeducation a week for one month, with a total of eight sessions. Effectiveness of the psychoeducation given was evaluated by comparing scores of Perceived Family Burden Scale (PFBS) and Positive and Negative Syndrome Scale (PANSS) obtained before and three months after delivery between the intervention and the control groups. Mean PFBS burden scores of the control group at baseline and follow-up were 45.7 and 44.5, respectively. Mean PFBS burden scores of the intervention group were 45.2 at baseline and 38.6 at follow-up. Analysis of variance revealed significant and medium to large size interaction effects of time and group factors on total burden scores of family members (F_1.58 = 5.59; p < 0.05; η_p² = 0.09) and on total PANSS scores of patients (F_1.58 = 104.78; p < 0.001; η_p² = 0.64). Our findings suggest that psychoeducation offered to the caregivers along with TAU offered to patients might result in diminished perceptions of burden among caregivers and enhanced improvement in the clinical course of patients as a result of psychoeducation offered to caregivers.

Family Interventions for Schizophrenia and the Psychoses: A Review

Family psychoeducation as a treatment for schizophrenia was developed 40 years ago almost simultaneously and independently by investigators who at the time were not family therapists. Although the original goal was to decrease high expressed emotion as a means of preventing relapse, later variations have gone beyond to focus on social and role functioning and family well-being. Explicitly disavowing the earlier assumptions that family pathology caused relapse and deterioration, family psychoeducation seeks to engage family members as more sophisticated partners, complementing interventions by clinicians with specialized interactions and coping skills that counter the neurologic deficits inherent to the disorder. It has proved to be one of the most consistently effective treatments available. Reports on outcome studies now number more than 100, while meta-analyses put relapse rate reduction at 50-60% over treatment as usual. The most recent application in first episode and prodromal psychosis, combined with other evidence-based interventions, is yielding perhaps the most promising results yet achieved-substantial return of functioning and avoidance of psychosis altogether. Reviewed here are its scientific, theoretical, and clinical sources, a description of the most commonly applied version-the multifamily group format, selected clinical trials spanning those four decades, international and ethnic adaptations, and studies on mechanisms of efficacy.

[How to involve patients with schizophrenia in their treatment using psychoeducation]

Schizophrenia is characterized not only by symptoms, but also by a reduced insight that contributes to functional outcomes through a bad acceptation of the disease and a low involvement in treatment and care. Functional outcomes of schizophrenia are conditioned by the acceptance of the troubles, by the involvement in psychopharmacological treatment and in psychosocial care and by the expressed emotion level of the family. Psychoeducation improves adherence to treatment. Psychoeducation lowers relapse rate. All the patients suffering from schizophrenia and their families should benefit from psychoeducation.

Recommendations for the optimal care of patients with recent-onset psychosis in the Asia-Pacific region

Providing optimal care to patients with recent-onset psychosis can improve outcomes and reduce relapse. However, there is a lack of consistency of the implementation of guidelines for such patients across the Asia-Pacific region. We determined a pragmatic set of recommendations for use on a day-to-day basis to help provide optimal care at this crucial stage of illness. The recommendations were developed over a series of meetings by an international faculty of 15 experts from the Asia-Pacific region, Europe, and South Africa. A structured search of the PubMed database was conducted. This was further developed based on the faculty's clinical experience and knowledge of the literature into 10 key aspects of optimal care for patients during the first five years of a diagnosis of a psychotic disorder, with particular relevance to the Asia-Pacific region. Several common principles emerged: adherence to antipsychotic medications is crucial; substance abuse, psychiatric and medical comorbidities should be addressed; psychosocial interventions play a pivotal role; and family members can play a vital role in overall patient care. By following these recommendations, clinicians may improve outcomes for patients with recent-onset psychosis.

A randomized trial to assess the efficacy of a psychoeducational intervention on caregiver burden in schizophrenia

BACKGROUND

Patient's relatives usually care for patients with schizophrenia, and as informal caregivers they experience negative consequences. The aim of the EDUCA-III trial is to test the efficacy of a psychoeducational intervention program (PIP) versus standard care to reduce the caregiver burden at post-intervention (4 months), and at follow-up (8 months).

METHOD

A two-arm, evaluator blind, multicentre, randomized controlled trial. The PIP group had 12 weekly group sessions. The control intervention group had the usual support and standard care. Primary outcomes were change scores since baseline on the Zarit Burden Interview (ZBI) and the Involvement Evaluation Questionnaire (IEQ).

RESULTS

One hundred and nine caregivers were randomized to PIP and 114 to control condition from 23 research sites. The decrease of ZBI scores was significantly higher on the PIP arm at 4 months (mean difference [MD]=-4.33; 95% CI -7.96, -0.71), and at 8 months (MD=-4.46; 95% CI -7.79, -1.13). There were no significant decreases in the IEQ scores (MD at 4 months=-2.80; 95% CI -6.27, 0.67; MD at 8 months=-2.85; 95% CI -6.51, 0.81).

CONCLUSIONS

The PIP condition seems to reduce caregiver burden.

TRIAL REGISTRATION

ISRCTN32545295.

A randomized controlled clinical trial of a nurse-led structured psychosocial intervention program for people with first-onset mental illness in psychiatric outpatient clinics

This study aimed to test the effectiveness of a nurse-led structured psychosocial intervention program in Chinese patients with first-onset mental illness. A single-blind, parallel group, randomized controlled trial design was used. The study involved 180 participants with mild to moderate-severe symptoms of psychotic or mood disorders who were newly referred to two psychiatric outpatient clinics in Hong Kong. Patients were randomly assigned to either an eight-session nurse-led psychosocial intervention program (plus usual care) or usual psychiatric outpatient care (both n=90). The primary outcome was psychiatric symptoms. Outcomes were measured at recruitment, one week and 12 months post-intervention. Patients in the psychosocial intervention group reported statistically significant improvements in symptoms compared to treatment as usual. There were also significant improvements in illness insight and perceived quality of life and reduction in length of re-hospitalizations over the 12-month follow-up. The findings provide evidence that the nurse-led psychosocial intervention program resulted in improved health outcomes in Chinese patients with first-onset mental illness.

[Psychosocial Interventions in Acute and Maintenance Treatment of Adult Patients Diagnosed With Schizophrenia]

OBJECTIVES

To determine the effectiveness of the psychosocial strategies designed to improve the outcomes in adults with schizophrenia in both, acute and stable phase of the disorder. This evidence is used to propose recommendation in the guidelines of integral attention for the diagnosis, treatment and psychosocial rehabilitation of adults with schizophrenia.

METHODS

A guideline for clinical practice was developed using the methodological framework of the Ministerio de la Protección Social to collect evidence and grading recommendations. A search, evaluation and synthesis of evidence were carried out. The evidence was presented to the Guideline Developing Group and recommendations, employing the GRADE system, were produced.

RESULTS

The psychoeducation and family intervention showed higher efficacy, compared with the usual treatment, to prevent relapses and hospital readmissions, to reduce family burden and to improve adherence to treatment. The social skill training was effective to improve symptoms, social functioning and quality of life. However, the quality of evidence was low. There was not enough evidence about the efficacy of occupational therapy, but considering patients preferences and its wide clinical utilization, the GDG suggested its inclusion.

CONCLUSION

Psychoeducation, family intervention and social skill training are recommended to be offered for the treatment of schizophrenia. Furthermore, occupational therapy is suggested for inpatients and outpatients with the disorder.

Psychoeducation for siblings of people with severe mental illness

BACKGROUND

Many people with severe mental illness (SMI) have siblings. Siblings are often both natural agents to promote service users' recovery and vulnerable to mental ill health due to the negative impact of psychosis within the family. Despite a wealth of research evidence supporting the effectiveness of psychoeducation for service users with SMI and their family members, in reducing relapse and promoting compliance with treatment, siblings remain relatively invisible in clinical service settings as well as in research studies. If psychoeducational interventions target siblings and improve siblings' knowledge, coping with caring and overall wellbeing, they could potentially provide a cost-effective option for supporting siblings with resulting benefits for service users' outcomes.

OBJECTIVES

To assess the effectiveness of psychoeducation compared with usual care or any other intervention in promoting wellbeing and reducing distress of siblings of people affected by SMI.The secondary objective was, if possible, to determine which type of psychoeducation is most effective.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register and screened the reference lists of relevant reports and reviews (12th November 2013). We contacted trial authors for unpublished and specific data on siblings' outcomes.

SELECTION CRITERIA

All relevant randomised controlled trials focusing on psychoeducational interventions targeting siblings of all ages (on their own or amongst other family members including service users) of individuals with SMI, using any means and formats of delivery, i.e. individual (family), groups, computer-based.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the abstracts and extracted data and two other authors independently checked the screening and extraction process. We contacted authors of trials to ascertain siblings' participation in the trials and seek sibling-specific data in those studies where siblings' data were grouped together with other participants' (most commonly other family members'/carers') outcomes. We calculated the risk difference (RD), its 95% confidence interval (CI) on an intention-to-treat basis. We presented continuous data using the mean difference statistic (MD) and 95% CIs. We assessed risk of bias for the included study and rated quality of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE).

MAIN RESULTS

We found 14 studies that included siblings amongst other family members in receipt of psychoeducational interventions. However, we were only able to include one small trial with relevant and available data (n = 9 siblings out of n = 84 family member/carer-participants) comparing psychoeducational intervention with standard care in a community care setting, over a duration of 21 months. There was insufficient evidence to determine the effects of psychoeducational interventions compared with standard care on 'siblings' quality of life' (n = 9, MD score 3.80 95% CI -0.26 to 7.86, low quality of evidence), coping with (family) burden (n = 9, MD -8.80 95% CI -15.22 to -2.34, low quality of evidence). No sibling left the study early by one year (n = 9, RD 0.00 CI -0.34 to 0.34, low quality of evidence). Low quality and insufficient evidence meant we were unable to determine the effects of psychoeducational interventions compared with standard care on service users' global mental state (n = 9, MD -0.60 CI -3.54 to 2.38, low quality of evidence), their frequency of re-hospitalisation (n = 9, MD -0.70 CI -2.46 to 1.06, low quality of evidence) or duration of inpatient stay (n = 9, MD -2.60 CI -6.34 to 1.14, low quality of evidence), whether their siblings received psychoeducation or not. No study data were available to address the other primary outcomes: 'siblings' psychosocial wellbeing', 'siblings' distress' and adverse effects.

AUTHORS' CONCLUSIONS

Most studies evaluating psychoeducational interventions recruited siblings along with other family members. However, the proportion of siblings in these studies was low and outcomes for siblings were not reported independently from those of other types of family members. Indeed, only data from one study with nine siblings were available for the review. The limited study data we obtained provides no clear good quality evidence to indicate psychoeducation is beneficial for siblings' wellbeing or for clinical outcomes of people affected by SMI. More randomised studies are justified and needed to understand the role of psychoeducation in addressing siblings' needs for information and support.

Interventions to improve the experience of caring for people with severe mental illness: systematic review and meta-analysis

BACKGROUND

Informal caregiving is an integral part of the care of people with severe mental illness, but the support needs of those providing such care are not often met.

AIMS

To determine whether interventions provided to people caring for those with severe mental illness improve the experience of caring and reduce caregiver burden.

METHOD

We conducted a systematic review and meta-analyses of randomised controlled trials (RCTs) of interventions delivered by health and social care services to informal carers (i.e. family or friends who provide support to someone with severe mental illness).

RESULTS

Twenty-one RCTs with 1589 carers were included in the review. There was evidence suggesting that the carers' experience of care was improved at the end of the intervention by psychoeducation (standardised mean difference -1.03, 95% CI -1.69 to -0.36) and support groups (SMD = -1.16, 95% CI -1.96 to -0.36). Psychoeducation had a benefit on psychological distress more than 6 months later (SMD = -1.79, 95% CI -3.01 to -0.56) but not immediately post-intervention. Support interventions had a beneficial effect on psychological distress at the end of the intervention (SMD = -0.99, 95% CI -1.48 to -0.49) as did problem-solving bibliotherapy (SMD = -1.57, 95% CI -1.79 to -1.35); these effects were maintained at follow-up. The quality of the evidence was mainly low and very low. Evidence for combining these interventions and for self-help and self-management was inconclusive.

CONCLUSIONS

Carer-focused interventions appear to improve the experience of caring and quality of life and reduce psychological distress of those caring for people with severe mental illness, and these benefits may be gained in first-episode psychosis. Interventions for carers should be considered as part of integrated services for people with severe mental health problems.

The evaluation of family functioning by the family assessment device: a systematic review of studies in adult clinical populations

A large body of research, documenting the impact of a family's functioning on health outcomes, highlights the importance of introducing the evaluation of patients' family dynamics into clinical judgment. The Family Assessment Device (FAD) is a self-report questionnaire designed to assess specific dimensions of family functioning. This qualitative systematic review, which follows PRISMA guidelines, aimed to identify the FAD's clinimetric properties and to report the incremental utility of its inclusion in clinical settings. A thorough literature search was performed, using both computerized and manual searches, yielding a total of 148 studies that were included in this review. The FAD has been extensively used in a variety of research contexts. In the majority of studies it was able to discriminate between clinical populations and controls and among groups of patients with different illnesses. The FAD also showed good test-retest and concurrent reliability, and modest sensitivity to change after treatment. FAD-dysfunctional family functioning was related to several patient clinical outcomes, including lower recovery rates and adherence to treatment, longer recovery time, poorer quality of life, and increased risk of relapse and drop-out. The present review demonstrates that the FAD is a suitable instrument for the evaluation of family functioning both in clinical and research settings.

Needs of siblings of persons with psychosis: a systematic descriptive review

Research on caregivers of psychosis has predominantly focused on parents and spouses. Issues related to siblings of persons with psychosis (SOPP) are yet to be evaluated comprehensively. Like parents and spouses, SOPP also share the caregiver burden and have their own issues and needs. This systematic descriptive review aims to identify the types of needs of SOPP in the published literature and gives implications for further practice and research. The primary data search was carried out with predefined protocol in PubMed database and an additional hand search was done in EBSCOhost, ProQuest, Scopus, and PsychINFO. All the searches yielded a total of 862 titles. After screening for necessary inclusion criteria, seven studies were included in the final review. The results are discussed under six major themes that emerged from this review. Six out of seven studies highlighted the need for information on siblings' illness and participation in caregiver support group. Other important needs were illness management or rehabilitation needs; help in managing their own psychosocial issues; treatment related informational needs; and inclusion in treatment process. The socio-demographic details of these studies showed that majority of the participants were female siblings of Caucasian or white British ethnicity and from developed countries. SOPP predominantly have specific needs such as informational and support group needs, which are different in the priority of other primary caregiver needs. Paucity of literature from developing countries and the limitations of the existing studies warrant further systematic research.

The effects of group psychoeducational programme on family burden in caregivers of Iranian patients with schizophrenia

This study was aimed at assessing the impact of group psychoeducation therapy on family burden in caregivers of Iranian patients with schizophrenia during the acute phase of the disease. Using a randomized-controlled trial design, 71 caregivers of patients with schizophrenia were randomly assigned to either a 4-week group psychoeducational programme (n = 36) or the control group (n = 35). Family burden was assessed by Family Burden Index Schedule (FBIS) at the beginning, and after a month of psychoeducation therapy as a follow-up. FBIS assesses family burden in six different dimensions with score ranging from 0 to 48, higher scores indicating higher burdens. At baseline mean, FBIS score was not significantly different between the cases and the controls. After the intervention, the mean total FBIS score was significantly lower in the case group compared with the control group (P < 0.001). In the intervention group, FBIS score change was significant through the study in all dimensions as well as the total score (P < 0.001). A significant reduction in family burden has been achieved by implementing group psychoeducational programmes for inpatients with acute phase schizophrenia in Iranian population.

The influence of perceived social support on medication adherence in first-episode psychosis

OBJECTIVE

Our study examines the unique influence of social and family support on adherence to medication in a sample of patients treated for first-episode psychosis (FEP).

METHOD

Social and family support using the Multidimensional Scale of Perceived Social Support and medication adherence (consensus of subjective and objective data) were evaluated on a monthly basis during a 6-month period in a sample of 82 FEP patients. The relation between social support and adherence was evaluated using correlational and linear regression analyses, controlling for other relevant variables. A longitudinal analysis using hierarchical linear models was conducted to model change in adherence over time.

RESULTS

Monthly correlations between social support and adherence were significant at 4 of 7 time points during a 6-month period. There was a modest correlation between the percentage of months of good adherence and the average level of family support across the study period. The linear regression failed to demonstrate a significant relation between baseline social support and overall adherence during the entire study period. Change in social support over time was inversely associated with change in adherence.

CONCLUSIONS

Our study emphasizes the concurrent influence of social (mostly family) support on adherence but this effect does not persist over time. Changes in the degree of social support may have a complex effect on changes in adherence.

Current approaches to treatments for schizophrenia spectrum disorders, part II: psychosocial interventions and patient-focused perspectives in psychiatric care

Schizophrenia is a disabling psychiatric illness associated with disruptions in cognition, emotion, and psychosocial and occupational functioning. Increasing evidence shows that psychosocial interventions for people with schizophrenia, as an adjunct to medications or usual psychiatric care, can reduce psychotic symptoms and relapse and improve patients' long-term outcomes such as recovery, remission, and illness progression. This critical review of the literature was conducted to identify the common approaches to psychosocial interventions for people with schizophrenia. Treatment planning and outcomes were also explored and discussed to better understand the effects of these interventions in terms of person-focused perspectives such as their perceived quality of life and satisfaction and their acceptability and adherence to treatments or services received. We searched major health care databases such as EMBASE, MEDLINE, and PsycLIT and identified relevant literature in English from these databases. Their reference lists were screened, and studies were selected if they met the criteria of using a randomized controlled trial or systematic review design, giving a clear description of the interventions used, and having a study sample of people primarily diagnosed with schizophrenia. Five main approaches to psychosocial intervention had been used for the treatment of schizophrenia: cognitive therapy (cognitive behavioral and cognitive remediation therapy), psychoeducation, family intervention, social skills training, and assertive community treatment. Most of these five approaches applied to people with schizophrenia have demonstrated satisfactory levels of short- to medium-term clinical efficacy in terms of symptom control or reduction, level of functioning, and/or relapse rate. However, the comparative effects between these five approaches have not been well studied; thus, we are not able to clearly understand the superiority of any of these interventions. With the exception of patient relapse, the longer-term (eg, >2 years) effects of these approaches on most psychosocial outcomes are not well-established among these patients. Despite the fact that patients' perspectives on treatment and care have been increasingly concerned, not many studies have evaluated the effect of interventions on this perspective, and where they did, the findings were inconclusive. To conclude, current approaches to psychosocial interventions for schizophrenia have their strengths and weaknesses, particularly indicating limited evidence on long-term effects. To improve the longer-term outcomes of people with schizophrenia, future treatment strategies should focus on risk identification, early intervention, person-focused therapy, partnership with family caregivers, and the integration of evidence-based psychosocial interventions into existing services.

Families and family therapy in Hong Kong

Family therapy views humans not as separate entities, but as embedded in a network of relationships, highlighting the reciprocal influences of one's behaviours on one another. This article gives an overview of family demographics and the implementation of family therapy in Hong Kong. We start with a review of the family demographics in Hong Kong and brief notes on families in mainland China. Demographics show that the landscape has changed markedly in the past decade, with more cross-border marriages, an increased divorce rate, and an ageing overall population - all of which could mean that there is increasing demand for professional family therapy interventions. However, only a limited number of professionals are practising the systems-based approach in Hong Kong. Some possible reasons as to why family therapy is not well disseminated and practised are discussed. These reasons include a lack of mental health policy to support family therapy, a lack of systematic family therapy training, and a shortage of skilled professionals. Furthermore, challenges in applying the western model in Chinese culture are also outlined. We conclude that more future research is warranted to investigate how family therapy can be adapted for Chinese families.

Family interventions in schizophrenia: Issues of relevance for Asian countries

A growing body of research evidence has confirmed the efficacy of family-interventions as adjuncts to antipsychotics for the treatment of schizophrenia. Much of the recent evidence for such interventions derives from Asian, principally Chinese, studies. These trials have shown that relatively simple forms of family-interventions have wide ranging benefits, and can be implemented successfully in routine clinical settings. With the accumulation of this evidence in their favour, family-interventions for schizophrenia in Asia are poised to take the next critical step, that of wider implementation and improved accessibility for potential users. However, several issues merit consideration. Family-interventions need to be based on a culturally-informed theory, which incorporates cultural variables of relevance in these countries. While the ideal format for conducting family-interventions is still to be determined, it is quite evident that for such interventions to be useful they need to be simple, inexpensive, needs-based, and tailored to suit the socio-cultural realities of mental health systems in Asian countries. The evidence also suggests that delivery by non-specialist personnel is the best way to ensure that such services reach those who stand to benefit most from these treatments. However, there are several existing challenges to the process of dissemination of family-interventions. The major challenges include the achievement of a critical mass of trained professionals capable of delivering these interventions, and finding innovative solutions to make family-interventions more acceptable to families. If these hurdles are overcome, we could look forward to a genuine collaboration with families, who have always been the mainstay of care for the mentally ill in Asia.

Psychoeducation for schizophrenia

BACKGROUND

Schizophrenia can be a severe and chronic illness characterised by lack of insight and poor compliance with treatment. Psychoeducational approaches have been developed to increase patients' knowledge of, and insight into, their illness and its treatment. It is supposed that this increased knowledge and insight will enable people with schizophrenia to cope in a more effective way with their illness, thereby improving prognosis.

OBJECTIVES

To assess the effects of psychoeducational interventions compared with standard levels of knowledge provision.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (February 2010).

SELECTION CRITERIA

All relevant randomised controlled trials focusing on psychoeducation for schizophrenia and/or related serious mental illnesses involving individuals or groups. We excluded quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data independently from included papers. We contacted authors of trials for additional and missing data. We calculated risk ratios (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data. We used a fixed-effects model for heterogeneous dichotomous data. Where possible we also calculated the numbers needed to treat (NNT), as well as weighted means for continuous data.

MAIN RESULTS

This review includes a total of 5142 participants (mostly inpatients) from 44 trials conducted between 1988 and 2009 (median study duration ˜ 12 weeks, risk of bias - moderate). We found that incidences of non-compliance were lower in the psychoeducation group in the short term (n = 1400, RR 0.52 CI 0.40 to 0.67, NNT 11 CI 9 to 16). This finding holds for the medium and long term. Relapse appeared to be lower in psychoeducation group (n = 1214, RR 0.70 CI 0.61 to 0.81, NNT 9 CI 7 to 14) and this also applied to readmission (n = 206, RR 0.71 CI 0.56 to 0.89, NNT 5 CI 4 to 13). Scale-derived data also suggested that psychoeducation promotes better social and global functioning. In the medium term, treating four people with schizophrenia with psychoeducation instead of standard care resulted in one additional person showing a clinical improvement. Evidence suggests that participants receiving psychoeducation are more likely to be satisfied with mental health services (n = 236, RR 0.24 CI 0.12 to 0.50, NNT 5 CI 5 to 8) and have improved quality of life.

AUTHORS' CONCLUSIONS

Psychoeducation does seem to reduce relapse, readmission and encourage medication compliance, as well as reduce the length of hospital stay in these hospital-based studies of limited quality. The true size of effect is likely to be less than demonstrated in this review - but, nevertheless, some sort of psychoeducation could be clinically effective and potentially cost beneficial. It is not difficult to justify better, more applicable, research in this area aimed at fully investigating the effects of this promising approach.

Psychoeducation for schizophrenia

BACKGROUND

Schizophrenia can be a severe and chronic illness characterised by lack of insight and poor compliance with treatment. Psychoeducational approaches have been developed to increase patients' knowledge of, and insight into, their illness and its treatment. It is supposed that this increased knowledge and insight will enable people with schizophrenia to cope in a more effective way with their illness, thereby improving prognosis.

OBJECTIVES

To assess the effects of psychoeducational interventions compared with standard levels of knowledge provision.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (February 2010).

SELECTION CRITERIA

All relevant randomised controlled trials focusing on psychoeducation for schizophrenia and/or related serious mental illnesses involving individuals or groups. We excluded quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data independently from included papers. We contacted authors of trials for additional and missing data. We calculated risk ratios (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data. We used a fixed-effects model for heterogeneous dichotomous data. Where possible we also calculated the numbers needed to treat (NNT), as well as weighted means for continuous data.

MAIN RESULTS

This review includes a total of 5142 participants (mostly inpatients) from 44 trials conducted between 1988 and 2009 (median study duration ˜ 12 weeks, risk of bias - moderate). We found that incidences of non-compliance were lower in the psychoeducation group in the short term (n = 1400, RR 0.52 CI 0.40 to 0.67, NNT 11 CI 9 to 16). This finding holds for the medium and long term. Relapse appeared to be lower in psychoeducation group (n = 1214, RR 0.70 CI 0.61 to 0.81, NNT 9 CI 7 to 14) and this also applied to readmission (n = 206, RR 0.71 CI 0.56 to 0.89, NNT 5 CI 4 to 13). Scale-derived data also suggested that psychoeducation promotes better social and global functioning. In the medium term, treating four people with schizophrenia with psychoeducation instead of standard care resulted in one additional person showing a clinical improvement. Evidence suggests that participants receiving psychoeducation are more likely to be satisfied with mental health services (n = 236, RR 0.24 CI 0.12 to 0.50, NNT 5 CI 5 to 8) and have improved quality of life.

AUTHORS' CONCLUSIONS

Psychoeducation does seem to reduce relapse, readmission and encourage medication compliance, as well as reduce the length of hospital stay in these hospital-based studies of limited quality. The true size of effect is likely to be less than demonstrated in this review - but, nevertheless, some sort of psychoeducation could be clinically effective and potentially cost beneficial. It is not difficult to justify better, more applicable, research in this area aimed at fully investigating the effects of this promising approach.

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.

Research on caregiving in Chinese families living with mental illness: a critical review

Much of the existing research on caregiving in families of individuals with mental illness has been conducted in Western societies. Therefore, the purpose of this review was to critically examine research on caregiving in families of individuals with mental illness living in Taiwan, Hong Kong, and Mainland China. A search using computerized databases, public search engines, and references from retrieved articles revealed 37 studies published from 1990 to 2009. Four studies were theory driven at an individual level, and one study was guided by a family-level framework. Thirty-two articles were quantitative studies, and 5 were qualitative studies. All but 5 of 37 studies were cross-sectional. Findings suggest that misconceptions about mental illness, behavior disturbances, inadequate social support, and the limited value placed on caregiving contribute to maladaptation. Future research should include longitudinal studies guided by culturally appropriate family frameworks and studies using mixed methods.

Efficacy and effectiveness of individual family intervention on social and clinical functioning and family burden in severe schizophrenia: a 2-year randomized controlled study

BACKGROUND

Empirical evidence of the efficacy and effectiveness of psychosocial family intervention and of the specificity of its effects on the course of schizophrenia is limited. The aim was to study the efficacy and effectiveness of psychosocial family intervention with regard to clinical and social functioning and family burden after controlling for compliance and several prognostic factors.

METHOD

A 2-year randomized controlled trial with blind assessments. Fifty patients with DSM-IV schizophrenia and persistent positive symptoms and/or previous clinical relapse were allocated to psychosocial family intervention, individual counselling and standard treatment versus individual counselling and standard treatment.

RESULTS

Family intervention was associated with fewer clinical relapses, hospitalizations and major incidents, and an improvement in positive and negative symptoms, social role performance, social relations, employment and family burden. The reduction in hospitalizations in the family intervention group was significantly greater than that observed in the group of patients who refused to participate but this was not the case for the control group. The effects of family intervention were independent of compliance and prognostic factors.

CONCLUSIONS

Family intervention is effective in severe schizophrenia independently of compliance and prognostic factors.

Packages of care for schizophrenia in low- and middle-income countries

In the third in a series of six articles on packages of care for mental disorders in low- and middle-income countries, Jair Mari and colleagues discuss the treatment of schizophrenia.

Psychoeducational intervention for caregivers of Indian patients with schizophrenia: a randomised-controlled trial

OBJECTIVE

There are hardly any randomised-controlled trials of structured family interventions for schizophrenia from India. This study attempted to evaluate the impact of a structured psychoeducational intervention for schizophrenia, compared with standard out-patient treatment, on various patient- and caregiver-related parameters.

METHOD

Seventy-six patients with DSM-IV schizophrenia and their caregivers were randomly allocated to receive either a structured psychoeducational intervention (n = 38) consisting of monthly sessions for 9 months or 'routine' out-patient care (n = 38) for the same duration. Psychopathology was assessed on monthly basis. Disability levels, caregiver-burden, caregiver-coping, caregiver-support and caregiver-satisfaction were evaluated at baseline and upon completion.

RESULTS

Structured psychoeducational intervention was significantly better than routine out-patient care on several indices including psychopathology, disability, caregiver-support and caregiver-satisfaction. The psychoeducational intervention package used was simple, feasible and not costly.

CONCLUSION

Structured psychoeducational intervention is a viable option for treatment of schizophrenia even in developing countries like India.