Carer psychoeducation in first-episode psychosis: evaluation outcomes from a structured group programme

Preferences for WeChat-Based and Hospital-Based Family Intervention Among Caregivers of People Living with Schizophrenia

PURPOSE

This study examines the preferences for WeChat-based and hospital-based family intervention among caregivers of people living with schizophrenia (PLS) and identify correlates associated with these preferences.

PATIENTS AND METHODS

A cross-sectional study was conducted with 449 family caregivers of PLS. Face-to-face interviews were conducted to collect information on socio-demographics, preferences for WeChat-based and hospital-based family intervention, social support, and coping.

RESULTS

Over 72.16% of participants endorsed hospital-based family intervention, while 50.11% endorsed WeChat-based family intervention. Endorsement of WeChat-based family intervention was associated with younger age (OR=0.42, 95% CI: 0.22, 0.79), WeChat use (OR=12.90, 95% CI: 7.48, 22.23), and higher social support (OR=1.03, 95% CI: 1.01, 1.04). Endorsement of hospital-based family intervention was associated with lower education (OR=0.19-0.37, 95% CI: 0.07, 0.66) and WeChat use (OR=3.27, 95% CI: 1.91, 5.59).

CONCLUSION

The studies showed a higher endorsement rate for hospital-based family intervention than WeChat-based family intervention and provide implications for developing targeted family intervention programs based on participants' own unique characteristics.

Psychoeducation for Inpatients With First-Episode Psychosis: Results From a Survey of Psychiatry Trainees in New York City

OBJECTIVE

In this study, the authors aimed to characterize psychoeducation provided to inpatients with first-episode psychosis (FEP) and their families.

METHODS

Psychiatrists were surveyed about how they provide psychoeducation to this population.

RESULTS

In total, 60 psychiatry trainees at nine New York City hospitals responded to the survey invitation. Almost all reported that they provide psychoeducation. Most (81% for patients, 84% for families) reported that psychoeducation content and delivery method were not uniform. The most frequently used delivery method was unstructured conversation (98%), followed by handouts (25% for patients, 26% for families). Responses from a national sample (N=167) revealed similar trends.

CONCLUSIONS

Most respondents provided some form of psychoeducation to hospitalized patients with FEP and their families. Few utilized a standardized method, and less than one-third incorporated supplemental materials. Inpatient psychoeducation for this population was largely informal, and patients and their families were not receiving consistent content and quality of information.

Review of Australian initiatives to reduce stigma towards people with complex mental illness: what exists and what works?

Background

Australian national mental health policy outlines the need for a nationally coordinated strategy to address stigma and discrimination, particularly towards people with complex mental illness that is poorly understood in the community. To inform implementation of this policy, this review aimed to identify and examine the effectiveness of existing Australian programs or initiatives that aim to reduce stigma and discrimination.

Method

Programs were identified via a search of academic databases and grey literature, and an online survey of key stakeholder organisations. Eligible programs aimed to reduce stigma towards people with complex mental illness, defined as schizophrenia, psychosis, personality disorder, or bipolar disorder; or they focused on nonspecific ‘mental illness’ but were conducted in settings relevant to individuals with the above diagnoses, or they included the above diagnoses in program content. Key relevant data from programs identified from the literature search and survey were extracted and synthesized descriptively.

Results

We identified 61 programs or initiatives currently available in Australia. These included face-to-face programs (n = 29), online resources (n = 19), awareness campaigns (n = 8), and advocacy work (n = 5). The primary target audiences for these initiatives were professionals (health or emergency), people with mental illness, family or carers of people with mental illness, and members of the general population. Most commonly, programs tended to focus on stigma towards people with non-specific mental illness rather than on particular diagnostic labels. Evidence for effectiveness was generally lacking. Face-to-face programs were the most well-evaluated, but only two used a randomised controlled trial design.

Conclusions

This study identified areas of strength and weakness in current Australian practice for the reduction of stigma towards people with complex mental illness. Most programs have significant input from people with lived experience, and programs involving education and contact with a person with mental illness are a particular strength. Nevertheless, best-practice programs are not widely implemented, and we identified few programs targeting stigma for people with mental illness and their families, or for culturally and linguistically diverse communities, Aboriginal and Torres Strait Islander communities and LGBTIQ people. These can inform stakeholder consultations on effective options for a national stigma and discrimination reduction strategy.

Caring for caregivers: Understanding and meeting their needs in coping with first episode psychosis

AIM

The first episode of psychosis is a challenging time for both patients and those who care for them. Although literature on treatment is plentiful, literature on how to best support caregivers is more scarce. This review was undertaken to better understand the caregiver experience, determine which interventions most effectively alleviate their burden and examine which other factors may affect outcomes.

METHODS

Articles were retrieved from PubMed and OVID using the following search terms: first episode psychosis (FEP), schizophrenia, caregiver, intervention and burden in various combinations. Only peer-reviewed articles germane to FEP caregiver experience and interventions written in English were included.

RESULTS

Caregivers can experience grief, guilt and anxiety during this time. While concerned for their loved one, their own lives take a back seat and their mental and physical health are adversely affected. Some are better prepared to cope and are typically warm, decisive, confident and optimistic. Their families are organized and flexible. Others are less prepared and are more likely to have poor self-esteem, use avoidant coping strategies and be overly critical. Their families are controlling and have difficulty with communication and balance. These caregivers stand to benefit most from interventions.

CONCLUSIONS

Effective interventions incorporate psychoeducation, problem solving strategies, peer support and clinician guidance. A higher level of interaction with facilitators and peers is associated with better results. Benefits include decreases in caregiver burden, depressive and anxious symptoms and feelings of shame and isolation. Although the literature has yet to isolate the key factors of a successful intervention, this review provides practical suggestions for clinicians and further illustrates the need for more research.

Family Experiences Prior to the Initiation of Care for First-Episode Psychosis: A Meta-Synthesis of Qualitative Studies

OBJECTIVES

This study systematically reviewed existing qualitative evidence of family members' experiences prior to the initiation of mental health services for a loved one experiencing their first episode of psychosis (FEP).

METHODS

A meta-synthesis review of published peer-reviewed qualitative studies conducted between 2010 and 2019 were included. Keyword searches were performed in four electronic databases and the reference lists of primary manuscripts. Two independent reviewers used the Critical Appraisal Skills Programme (CASP) qualitative checklist to assess methodological quality of each study.

RESULTS

A total of 365 articles were initially identified and 9 were articles identified in a secondary review and literature search. A total of 21 met inclusion criteria. Of those included in this review 169, mothers were the primary family to recall experiences. The meta-synthesis identified four major themes related to family member experiences prior to the initiation of mental health services for FEP: the misinterpretation of signs, the emotional impact of FEP on family members, the effect of stigma on family members, and engaging with resources prior to mental health services for FEP.

CONCLUSIONS

Additional research is needed to develop healthy communication strategies that effectively deliver educational information about psychosis. This meta-synthesis also identified the need to understand help-seeking behaviors among families of those with FEP in effort to reduce the duration of untreated psychosis and improve pathways to care often initiated by a family member.

Developing and implementing a culturally informed mily otivational ngagement trategy (FAMES) to increase family engagement in first episode psychosis programs: mixed methods pilot study protocol

INTRODUCTION

Despite the proven effectiveness of coordinated specialty care (CSC) programmes for first episode psychosis in the USA, CSC programmes often have low levels of engagement in family psychoeducation, and engagement of racial and ethnic minority family members is even lower than that for non-Latino white family members. The goal of this study is to develop and evaluate a culturally informed FAmily Motivational Engagement Strategy (FAMES) and implementation toolkit for CSC providers.

METHODS AND ANALYSIS

This protocol describes a mixed methods, multi-phase study that blends intervention mapping and the Promoting Action on Research in Health Services framework to develop, modify and pilot-test FAMES and an accompanying implementation toolkit. Phase 1 will convene a Stakeholder Advisory Committee to inform modifications based on findings from phases 1 and 2. During phase 1, we will also recruit approximately 200 family members to complete an online survey to assess barriers and motivation to engage in treatment. Phase 2 we will recruit five family members into a 3-month trial of the modified FAMES and implementation toolkit. Results will guide the advisory committee in refining the intervention and implementation toolkit. Phase 3 will involve a 16-month non-randomised, stepped-wedge trial with 50 family members from five CSC programmes in community-based mental health clinics to examine the acceptability, feasibility and initial impact of FAMES and the implementation toolkit.

ETHICS AND DISSEMINATION

This study received Institutional Review Board approval from Washington State University, protocol #17 812-001. Results will be disseminated via peer review publications, presentations at national and international conferences, and to local community mental health agencies and committees.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04188366).

Caregivers' experiences of service transitions in adult mental health: An integrative qualitative synthesis

Approximately 5% of the UK population live with serious mental health problems. Data show that informal caregivers of people with mental illness provide care for the highest number of hours compared to other illness and the economic cost of this care is highest in the UK when compared internationally. People living with serious mental health problems make transitions between different intensities of service as their needs fluctuate, including referral, admission, transfer or discharge. Although caregiving is associated with both stress and positive reward, service transitions are particularly associated with increased stress. This review aimed to investigate what is known about the experiences of informal caregivers during mental health service transitions. An integrative qualitative synthesis was conducted following searches in six bibliographic databases and of the grey literature. Studies published in English between 2001 and 2017 were included if the study focus was on serious mental health problems, the experiences of caregivers and service transitions. Eleven studies were included, appraised using the Mixed Methods Appraisal Tool and synthesised, resulting in four themes: (a) Caregiver information, (b) Caregiver involvement in decisions about care and treatment, (c) Accessing services, (d) Being a caregiver. Caregivers' experiences were similar during transitions to their usual caregiving role but they faced more challenges and their experiences were amplified. Concerns about confidentiality created barriers to information sharing. Continuity of professionals across transitions was helpful. Caregivers struggled to deal with their own conflicting emotions and with the behaviours of the person yet rarely received help. The review findings point to a need for continuity of professionals across service transitions, co-designed and delivered training for professionals and caregivers about information sharing, greater understanding of barriers to implementation of family interventions and interventions that address emotional needs of caregivers.

Case management in early psychosis intervention programme: Perspectives of clients and caregivers

AIM

This qualitative study explored the perspectives of clients and caregivers on case management provided by the Singapore Early Psychosis Intervention Programme (EPIP), with the intent to understand the salient aspects of case management from their perspective.

METHODS

Clients and their caregivers were recruited from the EPIP outpatient clinics. Focus group discussions (FGDs) were conducted at a community centre outside the hospital with 47 clients and 19 caregivers. Facilitators were experienced researchers who were not involved in the care of the clients and trained in qualitative research methodologies. All FGDs were audio recorded and transcribed verbatim with all participants' identifiers omitted to protect confidentiality. Qualitative data analysis was conducted using thematic analysis.

RESULTS

There were 11 themes that emerged from the FGDs: therapeutic alliance, holistic monitoring, collaborative role with other care providers, counselling and guidance, crisis management, bridging role, client-centred care, client empowerment and strength building, psychoeducation/education on illness, support and problem solving. "Problem solving" surfaced only from the client FGDs; the remaining themes were common to both groups.

CONCLUSIONS

The voices of clients and caregivers are important to EPIP case management service. This study has provided insights into their perspectives, understandings and lived experiences of case management and its impact on clients and caregivers.

Love and incomprehensibility: The hermeneutic labour of caring for and understanding a loved one with psychosis

Informal carers are increasingly involved in supporting people with severe and enduring mental health problems, and carers' perceptions impact the wellbeing of both parties. However, there is little research on how carers actually make sense of what their loved one is experiencing. Ten carers were interviewed about how they understood a loved one's psychosis. Data were analysed using a hermeneutic-phenomenological approach. Three themes described the carers' effortful quest to understand their loved one's experiences while maintaining their relational bonds. Carers described psychosis as incomprehensible, seeing their loved one as incompatible with the shared world. To overcome this, carers developed hermeneutic 'mooring points', making sense of their loved one's unusual experiences through novel accounts that drew on material or spiritual explanations. The findings suggest that informal carers resist biomedical narratives and develop idiosyncratic understandings of psychosis, in an attempt to maintain relational closeness. We suggest that this process is effortful - it is hermeneutic labour - done in the service of maintaining the caring relationship. Findings imply that services should better acknowledge the bond between carers and care-receivers, and that more relationally oriented approaches should be used to support carers of people experiencing severe mental health problems.

Modifying illness beliefs in recent onset psychosis carers: Evaluating the impact of a cognitively focused brief group intervention in a routine service

AIMS

At first-episode psychosis (FEP), many patients will be routed within familial networks and supported by informal carers who are predominately close family members such as parents. Carer burden, distress and poorer coping styles are associated with different illness beliefs. The current study sought to examine the impact and acceptability of a 3 session, cognitively informed, group intervention targeting illness beliefs previously linked to distress and poorer caregiving experiences in FEP carers.

METHODS

Carers attending a routine FEP service were invited to attend the group intervention and completed a measure of illness beliefs at baseline and post intervention.

RESULTS

Data on 68 carers with complete datasets are presented. Carers were predominately females (64.2%). Group attendance was linked to positive improvements in carer baseline beliefs about the negative consequences of the illness for the patient and themselves, attributions of blame about the illness to the patient and themselves and their overall understanding about the illness. Significant improvements in their understanding of the illness timeline and course, and confidence in dealing with difficulties were also identified.

CONCLUSIONS

A cognitively informed group approach to targeting the less adaptive illness beliefs reported by FEP carers may offer an effective and acceptable pathway to facilitate their understanding of the illness and adjustment. Further studies using controlled designs are required.

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.

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

INTRODUCTION

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Burnout in early course psychosis caregivers: the role of illness beliefs and coping styles

AIMS

In occupational settings, burnout is a common response to chronic exposure stressors and has been frequently documented in formal caregivers (i.e. paid psychiatric staff). However, the literature is limited on reports of burnout among informal caregivers and particularly within early psychosis groups. The current study sought to investigate reports of burnout in carers of young adults treated within a specialist early psychosis service and links with key appraisals reported about the illness and coping.

METHODS

Seventy-two carers completed the Maslach Burnout Inventory along with self-report measures of coping styles and illness beliefs.

RESULTS

Seventy-eight per cent of carers reported high burnout in at least one of the three key burnout markers (i.e. emotional exhaustion, depersonalization or low personal accomplishment). Seven per cent of carers met full criteria for high burnout across all the three domains. A carer's belief about the negative consequences of the illness for themselves was a significant predictor of emotional exhaustion and depersonalization. Low personal accomplishment was linked to a carer's less optimistic beliefs about the illness timeline and fewer reports of adaptive coping.

CONCLUSIONS

The results provide preliminary support for the importance of asking carers in the early illness phase about their experiences of caregiving. Targeted assessment may serve as a helpful tool to identify and intervene with carers in need of additional support with stress management, use of adaptive coping strategies, and balanced recovery focused information about psychosis.

Improving physical health of patients with severe mental disorders: a critical review of lifestyle psychosocial interventions

INTRODUCTION

People with severe mental disorders have a mortality rate that is more than two times higher than the general population, with at least a decade of potential years of life lost. People with mental disorders have a significantly higher risk of obesity, hyperglycemia and metabolic syndrome, which are related to modifiable risk factors, such as heavy smoking, poor physical activities, and inappropriate unhealthy diet, which can be improved through lifestyle changes. Areas covered: Lifestyle behaviours are amenable to change through the adoption of specific psychosocial interventions, and several approaches have been promoted. In the present review, the authors aim to: 1) critically analyze studies involving multimodal lifestyle interventions; 2) discuss the way forward to integrate these interventions in clinical routine care. Expert commentary: The psychoeducational approaches developed for the improvement of healthy lifestyle behaviours differ for several aspects: 1) the format (individual vs. group); 2) the setting (outpatient vs. inpatient vs. home-based); 3) the professional characteristics of the staff running the intervention (psychiatrists or nurses or dietitians or psychologists); 4) the active ingredients of the intervention (education only or inclusion of motivational interview or of problem solving); 5) the duration of treatment (ranging from 3 months to 2 years).

The Effects of Psychoeducation on the Expressed Emotion and Family Functioning of the Family Members in First-Episode Schizophrenia

The aim of this study was to determine the effects of the psychoeducation received by the family members of the patients with first-episode schizophrenia on the expressed emotion (EE) and the family functioning of the family members. This study has a quasi-experimental design with a control group. The sample of the study was 60 family members (30 experimental -30 control) of the patients with first-episode schizophrenia. The experimental group received 9 weeks of psychoeducation as a group. EE and family functioning were assessed at the beginning and at the end of the psychoeducation program. EE criticism/hostility and over involvement-protecting-intervention levels of the family members have decreased at the end of the psychoeducation (p < 0.05). Family functioning has changed too at the end of the psychoeducation (p < 0.05), and assessed as more healthy. Consequently, early psychoeducational groups may be effective in decreasing EE level and improving the family functioning for a family member of patient with first-episode schizophrenia.

Intervening Early with Family Members during First-Episode Psychosis: An Evaluation of Mental Health Nursing Psychoeducation within an Inpatient Unit

Provision of psychoeducation to families of service users experiencing a first-episode psychosis has been found to assist with relapse prevention and promoting recovery for service users. Psychoeducation also assists families to reduce isolation and gain relevant information and support. This study aimed to clarify the role inpatient staff can best have with families, targeted to the acute phase and early stage of the illness. Family members were provided an inpatient carer psychoeducation meeting and recruited for a feedback interview 6 months later. Findings suggest that family members require information provision and support during the admission, in addition to beneficial psychoeducation groups offered later in the community.