Services to families of adults with schizophrenia: from treatment recommendations to dissemination

Psychological factors of sibling caregivers of patients with severe mental disorders: an observational study

The goal of the present study is to explore the perception of the relationship with parental figures, traumatic experiences, personality traits and psychosocial characteristics of the participant sibling caregivers. The sample was composed of 30 sibling caregivers recruited at psychiatric facilities in Italy, and of 30 control siblings. The battery of instruments administered included Parental Bonding Instrument (PBI), Minnesota Multiphasic Personality Inventory 2 (MMPI-2), and The Inventory of Traumatic Experiences (TEC). This research found that sibling caregivers of patients with severe psychiatric pathologies are distinctly different from the siblings of the control group with respect to the perception of their relationship with parental figures more frequently regarded as dysfunctional, and were also characterized by a higher presence of traumatic experiences. The problematic relationship with parental figures, some traumatic experiences, and the burden of taking care of a sibling with psychiatric disorders are probably important variables with regards to the individual's overall psychological condition.

Coordinated Specialty Care Discharge, Transition, and Step-Down Policies, Practices, and Concerns: Staff and Client Perspectives

OBJECTIVE

In recent years, optimizing the process of transition and discharge from coordinated specialty care (CSC), a program that provides early intervention in psychosis, has emerged as an important focus area for program administrators, clinicians, and policy makers. To explore existing CSC policies and practices and to understand frontline provider and client views on discharge, the authors conducted a comprehensive analysis of staff and client interview data from the Mental Health Block Grant 10% Set-Aside Study.

METHODS

Data from 66 interviews with groups of CSC providers and administrators representing 36 sites and 22 states were analyzed, as well as data from interviews with 82 CSC clients at 34 sites. Transcripts were coded by using systematic content analyses.

RESULTS

Analyses of data from providers and administrators showed the heterogeneity of CSC program practices and strategies regarding discharge and highlighted a range of concerns related to postdischarge service accessibility and quality. Analysis of data from client interviews reflected the heterogeneity of transition challenges that clients confront. A significant number of participants reported concerns about their readiness for discharge.

CONCLUSIONS

CSC discharge policies and practices vary across CSC programs and states. Frequent clinician and client concerns about optimal program length, transition, and postdischarge services highlight the importance of sustained policy and research efforts to develop evidence-informed practice guidelines and possible modifications to the time-limited CSC model that currently dominates the field.

Psychoeducation and Problem-Solving Therapy as an Integrative Model of Mutual-Help Groups for People with Severe Mental Disorders: A Report from Brazil

This case study describes the "Entrelaços" Peer Support Program, a psychoeducational program of a psychiatric institution in the city of Rio de Janeiro that admitted, between 2011 and 2019, 246 people comprising family members and patients to participate in eight educational seminars followed by multifamily problem-solving groups in cycles that were 18 months in duration. Ninety percent of the participants who completed the program decided to create 7 mutual-help groups in the community independent of technicians and the institution. Community groups have already served spontaneously more than 214 families. They have organized scientific, social and anti-stigma events, expanded their social support network and demonstrated empowerment by switching from service users to peer providers to receive new families. This work is based on a pioneering model in Brazil that integrates psychoeducation with problem-solving therapy, spreading the benefits of education and peer-support with lower cost and greater representativeness.

Does religiosity predict attrition from a culturally-informed family treatment for schizophrenia that targets religious coping?

OBJECTIVE

People dealing with serious mental illness frequently report turning to religion to help cope with the disorder. However, little is known about how religion impacts commitment to psychotherapy programs for people with schizophrenia and their caregivers.

METHOD

In a sample of 64 families enrolled in a culturally informed family treatment for schizophrenia that targets religiosity, we hypothesized that patients and caregivers who use high levels of adaptive religious coping and low levels of maladaptive religious coping, would be less likely to drop out of treatment than their counterparts.

RESULTS

In line with hypotheses, results demonstrated that greater maladaptive religious coping was associated with fewer family therapy sessions attended. Contrary to expectations, greater adaptive religious coping was also associated with attending fewer family therapy sessions.

CONCLUSION

Results suggest that any type of religious coping may be associated with higher levels of attrition from family therapy. Perhaps spiritual/religious people are already getting support and guidance from their beliefs and practices that aid them in coping with mental illness. Results may also suggest that there is a "religiosity gap" in which religious individuals perceive a disconnect between their beliefs and the beliefs of their mental health providers. It is important to point out that in this study, of those who dropped out prematurely, nearly all did so before the religiosity segment of treatment even began. Modifying how family treatments are introduced early on in therapy to ensure they appear congruent with the beliefs and values of religious families may help to reduce attrition. (PsycINFO Database Record

Parents Caring For Adult Children With Serious Mental Illness

BACKGROUND

Parents often become the caregivers for their adult children with serious mental illness (SMI) due to the chronic and debilitating course of the illness and shortages in funding for community mental health services and residential placements.

OBJECTIVE

To examine parents' management styles when caring for adult children with SMI and parents' perspectives on what type of community-based mental health interventions would support and/or enhance overall family functioning.

DESIGN

A qualitative descriptive study using semistructured interviews with parents caring for adult children with SMI. The study was undergirded by Knafl and Deatrick's Family Management Style Framework.

RESULTS

Four major themes emerged from the data describing prolonged and difficult phases that parents and the family undergo in caring for an adult child with SMI.

CONCLUSIONS

Successful management of these phases must include increasing access to mental health information, mental health screening, early interventions, and violence prevention for adult children and their families.

Schizophrenia in the Netherlands: Continuity of Care with Better Quality of Care for Less Medical Costs

Background

Patients with schizophrenia need continuous elective medical care which includes psychiatric treatment, antipsychotic medication and somatic health care. The objective of this study is to assess whether continuous elective psychiatric is associated with less health care costs due to less inpatient treatment.

Methods

Data concerning antipsychotic medication and psychiatric and somatic health care of patients with schizophrenia in the claims data of Agis Health Insurance were collected over 2008–2011 in the Netherlands. Included were 7,392 patients under 70 years of age with schizophrenia in 2008, insured during the whole period. We assessed the relationship between continuous elective psychiatric care and the outcome measures: acute treatment events, psychiatric hospitalization, somatic care and health care costs.

Results

Continuous elective psychiatric care was accessed by 73% of the patients during the entire three year follow-up period. These patients received mostly outpatient care and accessed more somatic care, at a total cost of €36,485 in three years, than those without continuous care. In the groups accessing fewer or no years of elective care 34%-68% had inpatient care and acute treatment events, while accessing less somatic care at average total costs of medical care from €33,284 to €64,509.

Conclusions

Continuous elective mental and somatic care for 73% of the patients with schizophrenia showed better quality of care at lower costs. Providing continuous elective care to the remaining patients may improve health while reducing acute illness episodes.

Perceptions of Subjective Burden Among Latino Families Caring for a Loved One with Schizophrenia

The purpose of this study was to explore perceptions of subjective burden among Latino family members providing care for a loved one with schizophrenia. Data were collected from outpatient community mental health centers and featured 64 Latino family members who were primarily Spanish speaking and of Mexican origin. We used qualitative methods to examine subjective burden based on an open section of the Family Burden Interview Schedule. Five salient themes emerged capturing family members' subjective burden experience: (a) interpersonal family relationships, (b) emotional and physical health, (c) loss of role expectations, (d) religion and spirituality, and (e) stigma. Overall, findings illustrated that families perceived numerous challenges in their caregiving. Implications for research and practice among Latino family members are discussed.

Provision of group psychoeducation for relatives of persons in inpatient depression treatment--a cross-sectional survey of acute care hospitals in Germany

BACKGROUND

Depressive disorders are often recurrent and place a high burden on patients and their relatives. Psychoeducational groups for relatives may reduce relatives' burden, help prevent relapses in patients, and are recommended by the German "National Disease Management Guideline Unipolar Depression". Since there is limited knowledge on the provision of psychoeducational groups for relatives of persons in inpatient depression treatment, we conducted a survey among acute care hospitals in Germany.

METHODS

We conducted a two-step cross-sectional survey. Step I consisted of a questionnaire asking the heads of all psychiatric/psychosomatic acute care hospitals in Germany (N = 512) whether psychoeducational groups for relatives were provided within depression treatment, and if not, the reasons for not implementing them. In group offering hospitals the person responsible for conducting psychoeducational groups received a detailed questionnaire on intervention characteristics (step II). We performed descriptive data analysis.

RESULTS

The response rate was 50.2% (N = 257) in step I and 58.4% in step II (N = 45). 35.4% of the responding hospitals offered psychoeducational groups for relatives of patients with depressive disorders. According to the estimates of the respondents, relatives of about one in five patients took part in psychoeducational groups in 2011. Groups were mostly provided by two moderators (62.2%) as continuous groups (77.8%), without patients' participation (77.8%), with up to ten participants (65.9%), consisting of four or fewer sessions (51.5%) which lasted between one and one and a half hours each (77.8%). The moderators in charge were mostly psychologists (43.9%) or physicians (26.8%). Approximately one third used published manuals. Reasons for not conducting such psychoeducational groups were lack of manpower (60.1%), time (44.9%) and financial constraints (24.1%). 25.3% mentioned adequate concepts of intervention as a required condition for initiating such groups.

CONCLUSIONS

Only a small proportion of relatives of patients with depressive disorders participated in psychoeducational groups in 2011 in Germany. Mostly short interventions were favoured and main implementation barriers were scarce resources. Brief interventions that fit with healthcare routine should be developed and tested within randomised controlled trials. This could promote the provision of psychoeducational groups for relatives as evidence-based practice in inpatient depression treatment in Germany.

New challenges in family interventions for schizophrenia

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

Effectiveness of family work interventions on schizophrenia: evidence from a multicentre study in Catalonia

BACKGROUND

Despite their proven efficacy, family work interventions on families of patients with schizophrenia are not being implemented in routine clinical practice in contexts where expressed emotion levels among caregivers are relatively high.

AIMS

This study aimed to explore the effectiveness of a family work intervention in a Mediterranean environment in Catalonia, Spain.

METHOD

Participants were 23 patients and 35 key relatives in five different clinical settings. The family intervention was provided by 10 trained health care professionals during a nine-month period. A six-month follow-up was also conducted.

RESULTS

Statistically significant improvements were found in patients' clinical status, global functioning and social functioning levels, as well as in caregivers' burden of care. These results were maintained during follow-up.

CONCLUSION

This is the first study to explore the effectiveness of family intervention in a high-expressed emotion context in Catalonia. The findings add weight to the growing literature supporting these interventions in different cultural settings.

Family interventions in Schizophrenia: promise and pitfalls over 30 years

The stress of living with unpredictable, disturbing schizophrenic symptoms can erode interpersonal relationships. Stressful family interactions are associated with poorer prognosis. Several investigators have developed educational or more intensive skills-based family programs to increase illness knowledge and improve prognosis in schizophrenia. An extensive body of research supports the benefits of participating in family-based treatments for schizophrenia, especially those of longer duration and emphasizing skill development, in reducing relapse rates. In spite of the data, these programs are underimplemented and underutilized. Barriers to their use likely arise from patients, relatives, and mental health professionals. Newer programs, which include novel engagement strategies, target subpopulations with poor prognoses, or use innovative technologies, may make these programs more accessible to a wider range of families. Engaging individuals with schizophrenia and their loved ones in a collaborative effort to design new, more consumer-driven family interventions is warranted.

Predictors of caregiver satisfaction with mental health services

The objective of this study is to examine the relative contribution of three main factors (characteristics of services and service providers, characteristics of patients and caregivers, and impact of psychiatric illness) to caregiver satisfaction with services. Results of this study are based on the responses of 154 family caregivers of individuals with mental illnesses in Quebec, and indicate that these aspects play a predictive role in caregiver satisfaction with services. A multiple regression model explained 42% of the variance in satisfaction. Collaboration with professionals is the key determinant in the model, as it contributes more than any other variable to satisfaction. Results demonstrate the importance of obtaining a better understanding of caregivers' satisfaction with services in order to increase their involvement in community integration.

Benefits and difficulties in implementing family psychoeducational interventions for schizophrenia in mental health services: results from a multicentre Italian study

Aims – This study aims to explore: a) the feasibility of psycho-educational interventions for families of users with schizophrenia in clinical practice by trained staff; b) the benefits and problems encountered by professionals in the use of these interventions. Methods – 46 professionals from 23 Italian Mental Health Sen'ices (MHS) attended at a three-module training course in psycho-educational interventions and four supervisions in the subsequent year. Following the course, participants provided the intervention to families of users with schizophrenia. The difficulties and benefits encountered by trainees to use the intervention were registered on the Family Intervention Schedule.Results – 83% of the participants completed the training course. Following the course, the intervention started in 71 families from 17 MHS. 76% of trainees provided the intervention to 2-5 families, while 13% of them only held informative sessions on schizophrenia. During the supervision period, the organisational difficulties experienced by the professionals were stable, while the benefits increased. Differences in benefits and difficulties were detected in relation to the trainees’ experience and professional roles. Conclusions – It is possible to introduce psycho-educational interventions in MHS after a relatively brief period of training and supervision of the staff. Organisational difficulties need to be addressed to increase the dissemination of these interventions on a large scale.

Declaration of Interest: None of the authors has had any interest or he/she has received any form of support, including that from drug companies and honoraria for lectures and consultancies, potentially in conflict with this scientific work. None of the authors has received any form of fee for his/her participation in this study. This study was supported by grants received from the “M. Lugli” Foundation (grant n. 2/18/8) and from the National Institute of Health, Italy (grant no. 1AL/F3).

Outcomes of a randomized study of a peer-taught Family-to-Family Education Program for mental illness

OBJECTIVE

The Family-to-Family Education Program (FTF) is a 12-week course offered by the National Alliance on Mental Illness (NAMI) for family members of adults with mental illness. This study evaluated the course's effectiveness.

METHODS

A total of 318 consenting participants in five Maryland counties were randomly assigned to take FTF immediately or to wait at least three months for the next available class with free use of any other NAMI supports or community or professional supports. Participants were interviewed at study enrollment and three months later (at course termination) regarding problem- and emotion-focused coping, subjective illness burden, and distress. A linear mixed-effects multilevel regression model tested for significant changes over time between intervention conditions.

RESULTS

FTF participants had significantly greater improvements in problem-focused coping as measured by empowerment and illness knowledge. Exploratory analyses revealed that FTF participants had significantly enhanced emotion-focused coping as measured by increased acceptance of their family member's illness, as well as reduced distress and improved problem solving. Subjective illness burden did not differ between groups.

CONCLUSIONS

This study provides evidence that FTF is effective for enhancing coping and empowerment of families of persons with mental illness, although not for reducing subjective burden. Other benefits for problem solving and reducing distress are suggested but require replication.

An evaluation of Well Ways, a family education programme for carers of people with a mental illness

OBJECTIVES

Family education programmes aim to improve the well-being of carers of people with a mental illness. We evaluated the effectiveness of one such programme, Well Ways, in reducing negative care-giving consequences.

METHOD

We employed a pre-post design to evaluate the effectiveness of Well Ways in a naturalistic setting using a sample of carers of people with a mental illness. The Involvement Evaluation Questionnaire, a measure of care-giving consequences including worrying, tension, urging and supervision, and incorporating the General Health Questionnaire-12 (GHQ-12), was completed by 459 carers before and after participation in Well Ways.

RESULTS

Participants' worrying, tension, urging and distress (GHQ-12) were significantly lower following completion of the programme. These improvements were maintained at 3 and 6 month follow up. Carers of people with a psychotic disorder experienced significantly greater reductions in worrying than did other carers. Females reported significantly greater reductions in tension than did males.

CONCLUSIONS

Findings indicated support for the effectiveness of the Well Ways programme in reducing negative care-giving consequences for families of people with a mental illness. Given the evidence of poor psychological health and negatively appraised family relationships observed at baseline, these findings highlight the need for programmes such as Well Ways.

The Meriden Family Programme: lessons learned over 10 years

BACKGROUND

Psychoeducational family approaches are effective in improving the quality of life for both those with mental health problems and their families, but implementation of these approaches within health services has been limited. The Meriden Family Programme has provided training and support for over 3,900 therapists and 242 trainers in Behavioural Family Therapy (BFT) to encourage widespread delivery of effective services for families with a member who has psychosis or other serious mental health problems.

AIMS

This article synthesises healthcare professionals' and carers' views on the implementation of family work and ways of increasing family involvement in services.

METHODS

During the Meriden Programme's 10th anniversary year, three Masterclass groups (n = 27) were conducted with healthcare professionals and carers involved with the programme over the past 10 years.

RESULTS

A collaborative approach between management, commissioners, BFT trainers, therapists, carers and service users encourages and ensures the delivery of family work. The most effective types of support, methods of training and organisational factors in supporting family work implementation are illustrated.

CONCLUSIONS

Best practices in implementing family work are identified to support and better inform those responsible for providing family work within their services.

Implementation of a family intervention for individuals with schizophrenia

BACKGROUND

Families are rarely included in clinical care despite research showing that family involvement has a positive effect on individuals with schizophrenia by reducing relapse, improving work functioning, and social adjustment.

OBJECTIVES

The VA QUERI study, EQUIP (Enhancing QUality of care In Psychosis), implemented family services for this population.

DESIGN

At two VA medical centers, veterans with schizophrenia and their clinicians were interviewed separately at baseline and 15 months. A family intervention was implemented, and a process evaluation of the implementation was conducted.

PARTICIPANTS

Veterans with schizophrenia (n = 173) and their clinicians (n = 29).

INTERVENTION

Consent to contact family was obtained, mailers to engage families were sent, families were prioritized as high need for family services, and staff volunteers were trained in a brief three-session family intervention.

MAIN RESULTS

Of those enrolled, 100 provided consent for family involvement. Seventy-three of the 100 were sent a mailer to engage them in care; none became involved. Clinicians were provided assessment data on their patients and notified of 50 patients needing family services. Of those 50, 6 families were already involved, 34 were never contacted, and 10 were contacted; 7 new families became involved in care. No families were referred to the family psychoeducational program.

CONCLUSIONS

Uptake of the family intervention failed due to barriers from all stakeholders. Families did not respond to the mailer, patients were concerned about privacy and burdening family, clinicians had misperceptions of family-patient contact, and organizations did not free up time or offer incentives to provide the service. If a full partnership with patients and families is to be achieved, these barriers will need to be addressed, and a family-friendly environment will need to be supported by clinicians and their organizations. Applicability to family involvement in other disorders is discussed.

A proof of concept trial of an online psychoeducational program for relatives of both veterans and civilians living with schizophrenia

OBJECTIVES

Family psychoeducation has been found to reduce relapse in schizophrenia but penetration rates are low. In this study, we evaluate the feasibility of an online multifamily group program for relatives of persons with schizophrenia that can be accessed from participants' homes.

METHODS

We explored participation rates and evaluations of a 12-month multimodal website intervention. Using a quasi-experimental design, we compared illness outcomes (factors on the Brief Psychiatric Rating Scale, hospitalizations) of persons with diagnosed schizophrenia, and relative distress outcomes (somatic concerns and anxiety/depression subscales on the Brief Symptom Inventory) from relatives participating in the intervention (n = 26) to archival data we had from comparable dyads who received customary care (n = 16).

RESULTS

The majority of participants in the program attended more than half the core online support sessions, expressed high levels of satisfaction, and found the technology easy to access. There appeared to be little impact of online participation on clinical status of persons with schizophrenia or relatives' distress, although there was a trend for fewer hospitalizations in the online group. Small sample size is a factor in interpreting results.

CONCLUSIONS

Online interventions for relatives of persons with schizophrenia, while feasible, present unique challenges. These include 1) assuring access to the intervention in populations who do not own a computer; 2) addressing privacy concerns; 3) overcoming the special challenges of conducting groups in real time; 4) managing emergent situations adequately; and 5) questions about efficacy.

Enhancing and Adapting Treatment Foster Care: Lessons Learned in Trying to Change Practice

Evidence-based practices to improve outcomes for children with severe behavioral and emotional problems have received a great deal of attention in children's mental health. Therapeutic Foster Care (TFC), a residential intervention for youth with emotional or behavioral problems, is one of the few community-based programs that is considered to be evidence-based. However, as for most treatment approaches, the vast majority of existing programs do not deliver the evidence-based version. In an attempt to fill this gap and improve practice across a wide range of TFC agencies, we developed an enhanced model of TFC based on input from both practice and research. It includes elements associated with improved outcomes for youth in "usual care" TFC agencies as well as key elements from Chamberlain's evidence-based model. The current manuscript describes this "hybrid" intervention - Together Facing the Challenge - and discusses key issues in implementation. We describe the sample and settings, highlight key implementation strategies, and provide "lessons learned" to help guide others who may wish to change practice in existing agencies.

Child and family inclusive practice: a pilot program in a community adult mental health service

OBJECTIVE

The aim of this paper is to describe the Child and Family Inclusive Practice program (CFIP), a pilot program implemented in an adult community mental health centre in Newcastle, New South Wales, which aimed to enhance family relationships through child and family inclusive practice.

CONCLUSIONS

The CFIP used a family-focused, child-sensitive approach in which two clinicians met together with families where there was parental mental illness. Adults and children were seen together and separately. Work with parents was aimed at validating their concerns for the child, and enhancing their confidence as parents/carers. Children had the opportunity to express their concerns in a safe and protective environment and, where appropriate, were supported in their concerns if these were being put to the adult family members. The project was seen to add value to the service provision of the community mental health team, and demonstrated to clinical staff the benefits of an inclusive and whole of family approach to mental health care.

Parenting adults who become homeless: variations in stress and social support

This article focuses on the stressors of parenting an adult child who experiences homelessness. Parents whose adult children become homeless may provide support to this child, but they may also subsequently experience stress and require social support themselves. Findings from this study support the hypothesis that parents who spend more time or money helping their homeless adult offspring experience higher levels of stress. Results also show higher levels of stress among parents who helped with activities of daily living and among parents who worked to prevent harm involving their adult homeless offspring. Among 37 respondents, a majority of whom were African American mothers parenting homeless sons, parents who engaged in activities to prevent harm and parents who experienced stress from harm prevention received more extensive social support. Health and social service providers should recognize and respond to the financial, emotional, and temporal burdens of parenting an adult who becomes homeless. Service providers can both support people who become homeless and reinforce larger family systems, particularly in circumstances that involve more extensive parental support or more harmful situations.

Attitudes and perceived barriers to working with families of persons with severe mental illness: mental health professionals' perspectives

A state-wide survey of 453 clinicians serving people with severe mental illness in community mental health centers evaluated the degree to which they provide services to families and their perceptions of barriers to developing such services. Most clinicians did not provide many services to families and reported barriers related to the family or client (e.g., family's lack of interest) and their own work environment (e.g., heavy workload). Clinicians who had received prior training on working with families provided more services, had more positive attitudes toward family, and felt more competent about their knowledge, confirming the importance of staff training.

Benefits and changes for family to family graduates

Family members of people with serious mental illnesses (SMI) need information and support to cope with the considerable stresses they experience. The Family to Family Education Program (FtF) is a structured, peer-led, 12-week information and support self-help class for such individuals. Previous research by Dixon et al. (2004) shows reduced subjective burden and increased empowerment among graduates. The present study sought to understand what processes take place during FtF participation that might lead to these benefits, as a first step in building a conceptual model of how FtF causes its effects, using semi-structured interviews with 31 FtF graduates. Qualitative data analysis suggested that new factual and emotional information from FtF shifts interviewees' understanding of their situation and that skills acquired through FtF then allow participants to incorporate these new perspectives into more adaptive behaviors. These changes led to both proximal and distal benefits for the FtF participants interviewed. The results are discussed in the context of self-help, stress-and-coping, and trauma recovery theories.

Workshop-based training in trauma-focused CBT: an in-depth analysis of impact on provider practices

Despite evidence that more intensive methods are more effective, many clinical settings continue to train practitioners using workshops. To more fully understand the strengths and limitations of workshops, the present investigation studied changes in practitioner behavior following a workshop in trauma-focused cognitive-behavioral therapy (TF-CBT). A chart review indicated no changes in TF-CBT use following the training, although therapists indicated that CBT was the most effective treatment for traumatized youths and was their primary approach to treating trauma. Analysis of client factors indicated weak relationships between technique use and treatment need. Implications of these findings for future training efforts are discussed.

Psychotic-spectrum illness and family-based treatments: a case-based illustration of the underuse of family interventions

Psychotic-spectrum illnesses (PSIs) are a significant cause of relational dysfunction and vocational disability, and result in substantial economic costs to society. The impact of family process, particularly "expressed emotion," on influencing the relapse rate of PSIs is now well documented. Over the last two decades, evidence has emerged supporting family-based treatments that decrease family stress (e.g., psychoeducation, training in problem solving, and improved communication), reduce the relapse rate, and improve medication adherence and social functioning among patients with PSIs. Family interventions are now included in the Expert Consensus Guidelines and the Agency for Health Care Policy and Research/National Institute of Mental Health (AHCPR/NIMH) Schizophrenia Patient Outcomes Research Team (PORT) recommendations for the treatment of schizophrenia. Nevertheless, family-based treatments are underused in the care of PSI patients. Building upon a case example, this article explores the barriers to implementing family interventions in the acute and outpatient treatment of these patients. The case discussion highlights the convergence of problems in the mental health care system with clinicians' typical capacities and practices, difficulties intrinsic to the nature of PSI itself, and the burden and stigmatization of families of the severely mentally ill. Taken together, these factors undercut the implementation of evidence-based family interventions.

Psychoeducation in schizophrenia--results of a survey of all psychiatric institutions in Germany, Austria, and Switzerland

INTRODUCTION

Psychoeducation can reduce rehospitalization rates and mental health costs in schizophrenia. The aims of this study were to investigate the percentage of patients and family members participating in psychoeducation in the year 2003 and to evaluate how psychoeducation was conducted.

METHODS

Part I of a 2-part postal survey was sent to the heads of all psychiatric institutions in Germany, Austria, and Switzerland; part II was sent directly to the moderators of psychoeducational groups. Responses were analyzed using descriptive statistics.

RESULTS

Psychoeducation was offered in 86% of the responding institutions and in 84% of these for schizophrenia (response quotas: part I, 54%; part II, 55%). A mean of 21% of the patients with schizophrenia and 2% of their family members had taken part in psychoeducation in the responding institutions in the year 2003.

DISCUSSION

Many readmissions and thus significant costs to the health system and substantial human suffering could be avoided if more patients and their family members participated in psychoeducation. New approaches to offering more psychoeducation would consist in integration of the entire psychiatric team into psychoeducation and peer-to-peer strategies.

Experiences and Demands of Families With Mentally Ill People at Home in Botswana

PURPOSE

To describe the experiences and demands of families who care for their mentally ill relatives at home in Botswana.

DESIGN

Grounded theory design with triangulated data sources.

METHODS

A convenience sample was drawn from both urban and rural areas and composed of both men and women. Data-collection methods included in-depth interviews, focus group discussions and field observations. Data were collected using an interview protocol in the local language. Interviews were audiotaped, transcribed, and translated into English. Analysis was done by open and axial coding and grouping like data together to generate core categories, using the constant comparison method.

FINDINGS

The interview data revealed a myriad of experiences and problems that families encountered in providing care to their relatives. The situation was perceived as difficult and burdensome because of lack of control and inadequate resources. The complexity of the situation required negotiation between the family members, their ill relatives, and health professionals.

CONCLUSIONS

This study indicated some of the difficulties caregivers encounter and the coping mechanisms they use to deal with the day-to-day care of their ill relatives. Community resources are needed to assist families to effectively care for their relatives.

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

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

Effects of a mutual support group for families of Chinese people with schizophrenia: 18-month follow-up

BACKGROUND

Family intervention in schizophrenia can reduce patient relapse and improve medication adherence, but few studies on this have involved a Chinese population.

AIMS

To examine the effects of a mutual support group for Chinese families of people with schizophrenia, compared with psychoeducation and standard care.

METHOD

Randomised controlled trial in Hong Kong with 96 families of out-patients with schizophrenia, of whom 32 received mutual support, 33 psychoeducation and 31 standard care. The psychoeducation group included patients in all the sessions, the mutual support group did not. Intervention was provided over 6 months, and patient- and family-related psychosocial outcomes were compared over an 18-month follow-up.

RESULTS

Mutual support consistently produced greater improvement in patient and family functioning and caregiver burden over the intervention and follow-up periods, compared with the other two conditions. The number of readmissions did not decrease significantly, but their duration did.

CONCLUSIONS

Mutual support for families of Chinese people with schizophrenia can substantially benefit family and patient functioning and caregiver burden.

Challenges to implementing and sustaining comprehensive mental health service programs

The President's New Freedom Commission recently concluded that the nation's mental health service delivery system is ill equipped to meet the complex needs of persons with mental illness. A major contributor to this service quality crisis has been the longstanding divergence of research efforts and clinical programs. In this article, the authors begin by describing the unique needs of persons with serious and persisting psychiatric disorders and the evolution of the mental health service system that has attempted to meet these needs. They then discuss recent efforts to upgrade services by emphasizing the use of evidence-based practices (EBPs) and the research underlying their development. Next, they describe the difficulties of using traditional research methods to develop and test interventions for persons receiving services at public mental health agencies. Finally, they outline the challenges confronted when trying to disseminate these EBPs to the wider clinical community.

Updates and five-year evaluation of the S.A.F.E. program: a family psychoeducational program for serious mental illness

This brief report reviews recent updates to the S.A.F.E. Program, a family psychoeducational intervention for serious mental illness created in the Veterans Affairs (VA) system. The improvements and significant content additions to the curriculum are outlined. Further, positive five-year program evaluation data are described, including high levels of participant retention and satisfaction. Program attendance is positively correlated with understanding of mental illness, awareness of VA resources, and ability to engage in self-care activities-and inversely correlated with caregiver distress. This data lays the groundwork for a randomized clinical trial and raises questions about the necessity of diagnostic-specific family programming.

Correlates of family contact with the mental health system: allocation of a scarce resource

This study explored correlates of informal and formal contact between clinicians and families of individuals with schizophrenia. We reanalyzed data from 902 individuals with schizophrenia from the Schizophrenia Patient Outcomes Research Team (PORT) client survey and a Veterans Affairs extension. Only 31% of families had any informal contact with a clinician and 7.8% attended a formal support program. Logistic regression showed that younger age, greater education, drug problems, receiving psychiatric inpatient and day treatment services, and participants' satisfaction with their family were all positively and significantly associated with informal contact. Receipt of formal family services was associated with intensity of social contact between participants and families. These results suggest that formal services for families of individuals with schizophrenia are not commonly available, and that informal pathways are the most common, although still limited, mechanism through which families of those patients who are receiving intensive services communicate with clinicians.

Effectiveness of a mutual support group for families of patients with schizophrenia

AIM

This paper reports a study to examine the effectiveness of a 12-session mutual support group for Chinese families caring for a relative with schizophrenia compared with a psycho-educational group and routine family support services in Hong Kong.

BACKGROUND

Schizophrenia is a disruptive and distressing illness for patients and their families. With the current trend of community care for mental illness, there is evidence that family intervention reduces patient relapse and re-hospitalization, satisfies the health needs of families and enhances their coping capabilities.

METHODS

A randomized controlled trial was conducted from May 2002 to June 2003 with 96 Chinese families of a relative with schizophrenia selected from two psychiatric outpatient clinics in Hong Kong. Families were randomly assigned to receive mutual support (n = 32), psycho-education (n = 33) or standard care only (n = 31). The interventions were delivered at outpatient clinics over a 6-month period. Pre- and post- (1 week and 6 months) testing took place and families' functioning, mental health service utilization, patients' level of functioning and duration of re-hospitalization were measured.

RESULTS

At both post-test periods, family caregivers and patients in the mutual support group reported statistically significant improvements on family and patients' level of functioning, when compared with their counterparts in the psycho-education and standard care groups.

CONCLUSIONS

The findings support the use of mutual support groups as an effective modality of family intervention in a Chinese population caring for a family member with schizophrenia to improve both family and patient functioning.

The role of relatives in discharge planning from psychiatric hospitals: the perspective of patients and their relatives

This study prospectively assessed the preferences and satisfaction of 98 psychiatric inpatients and 40 of their relatives with family involvement in discharge planning. Preferences questionnaires were administered during hospitalization. Satisfaction questionnaires were completed 3 months later. Preferences noted by most participants included information concerning patient health status, ways to prevent further hospitalizations, services for relatives, and signs of patient decompensation. More relatives than patients felt that post-discharge residence and activities were important areas to be involved in. Most participants were satisfied if relatives were involved in discharge planning. However, up to 89% of patients, and 84% of relatives, reported no communication between clinical staff and relatives regarding discharge. When this was the case, satisfaction rates dropped sharply, especially for relatives. The need for increased communication between clinicians and relatives regarding discharge planning remains a problem.

Provider contact with families of adults with severe mental illness: taking a closer look

This exploratory study examined the frequency and nature of providers' contact with families of persons with severe mental illness. Fifty-nine providers in six community mental health programs completed a self-administered survey. A subsample of 8 providers also completed two in-depth interviews. Although most providers had some family contact, the contact was restricted to a small percent of their caseloads. The nature of contact that providers have with families is generally limited by their professional role. Best practice guidelines for the treatment of mental illness and agency administrators responsible for instituting these guidelines will need to clarify the types of providers who are expected to implement various aspects of family involvement.

Educational needs of families caring for Chinese patients with schizophrenia

BACKGROUND

Schizophrenia is a disruptive and distressing illness for patients and family members who care for them. As in Western countries more than 20% of people with schizophrenia in Hong Kong are discharged to their homes, but their families are unprepared to care for them. Studies of caregivers' opinions about the information required to supervise patients are limited, particularly for the purposes of optimizing family-centred care.

AIM

The aim of this study was to identify the educational needs of Chinese families caring for a relative with schizophrenia.

METHODS

A cross-sectional survey was conducted in Hong Kong with a random sample of 204 family members caring for a relative with schizophrenia. A Chinese version of the Modified Educational Needs Questionnaire, validated in a previous study, was used to identify educational needs that family caregivers considered important in caring for mentally ill relatives.

FINDINGS

Educational needs perceived as important by caregivers included gaining information about early warning signs of illness and relapse, effects of medication and ways of coping with patients' bizarre and assaulting behaviour. Gender, education level and closeness of the relationship with the patient correlated positively and significantly with need importance. Conversely, the relationship between duration of caring for patient and need importance correlated significantly but negatively, indicating the adverse effect of enduring mental illness on family caregivers' interest in mental health education.

CONCLUSION

This study emphasizes the importance of assessing specific family needs in caring for a relative with mental illness. It also raises concern about the negative effects of the length of time of caring for such patients and the role of socio-economic factors on the perceived educational needs of these families.

Families' experience during recovery or nonrecovery from psychosis

This naturalistic qualitative study was conducted to expand understanding of families' subjective experiences to their relative's recovery or non recovery from psychosis. Nine families, who had a member with a chronic mental illness who was taking a second generation neuroleptic medication, were interviewed five times over the course of one year. Eight families reported positive outcomes, particularly valuing improved interpersonal relationships. Cautious optimism was restored. Interest in maintaining or establishing collaborative relationships with professionals was affirmed regardless of the length of their relative's psychotic experience. Nonrecovery punctuated the need for professionals to assist them to maintain hope while comforting them in their sorrow.

Strategies for leading the implementation of evidence-based practices

Many mental health authority and program administrators would like to implement behavioral health practices that have been demonstrated to be effective. Leading practice implementation involves promoting behavior change in health care providers. Reviews of the general medical literature on practice change conclude that education alone has little impact on practitioner behavior and that intensive, multifaceted interventions that attend to local circumstances have the greatest likelihood of affecting change. This article briefly reviews the literature on health care practice change and offers some strategy suggestions for administrators who are leading evidence-based practice implementation initiatives.

Family psychoeducation and schizophrenia: a review of the literature

Family psychoeducation has emerged as a treatment of choice for schizophrenia, bipolar disorder, major depression, and other disorders. More than 30 randomized clinical trials have demonstrated reduced relapse rates, improved recovery of patients, and improved family well-being among participants. Interventions common to effective family psychoeducation programs have been developed, including empathic engagement, education, ongoing support, clinical resources during periods of crisis, social network enhancement, and problem-solving and communication skills. Application of family psychoeducation in routine settings where patients having these disorders are usually treated has been limited, reflecting attitudinal, knowledge, practical, and systemic implementation obstacles. Through consensus among patient and family advocacy organizations, clinician training, and ongoing technical consultation and supervision, this approach has been implemented in routine clinical settings.