Expressed emotion and socio-demographic and clinical factors in families of Brazilian patients with schizophrenia

Family in Crisis: Do Halfway Houses Perform Better Than Families with Expressed Emotion toward Patients with Schizophrenia? A Direct Adjusted Comparison

Expressed emotion (EE) toward patients with schizophrenia is typically reported to be lower in psychiatric halfway houses than in families. This is the first study directly comparing EE between these settings and investigating the pathways mediating EE differences. We included 40 inpatients in halfway houses and 40 outpatients living with their families and recorded 22 psychiatric nurses' and 56 parents' EE, respectively, through Five Minutes Speech Samples. Each inpatient was rated by 2-5 nurses and each outpatient by 1-2 parents. As EE ratings had a multilevel structure, generalized linear mixed models were fitted, adjusting for patient-related confounders and caregiver demographics. Mediatory effects were investigated in multilevel structural equation models. Outpatients were younger, less chronic, and better educated, with higher negative symptoms and perceived criticism than inpatients. Nurses were younger and better educated than parents. Before adjustment, EE rates were equally high across settings. After adjusting for patient-related confounders, emotional overinvolvement was significantly higher in parents. However, after also adjusting for caregiver demographics, only criticism was significantly higher in nurses. Patients' age, negative symptoms, and perceived criticism and caregivers' age and sex significantly mediated EE group differences. Our findings highlight pathways underlying EE differences between halfway houses and families and underscore the importance of staff and family psychoeducation.

Differential correlates of criticism versus emotional overinvolvement towards patients with schizophrenia living in halfway houses or with their families

PURPOSE

This study systematically searched for differential correlates of criticism vs. emotional overinvolvement (EOI) towards patients with schizophrenia in families and halfway houses, which have only incidentally been reported in previous research. Identified patterns were compared across settings.

METHODS

We included 40 inpatients with schizophrenia living in halfway houses and 40 outpatients living with their families and recorded the expressed emotion (EE) of 22 psychiatric nurses or 56 parents, respectively, through Five Minutes Speech Samples. Each nurse rated 1-12 inpatients and each inpatient was rated by 2-5 nurses. Each outpatient was rated by one or both parents. As EE ratings had a multilevel structure, weighted Spearman correlations of criticism and EOI with various patient- and caregiver-related characteristics were calculated and compared with Meng's z-test.

RESULTS

Criticism was weakly negatively correlated with EOI in nurses but negligibly in parents. Distinct patterns of significant differential correlates arose across settings. Outpatients' aggressive behavior and parents' related burden were mainly associated with higher criticism. Inpatients' symptoms (agitation/aggression, negative and other psychotic symptoms) and nurses' burnout (Depersonalization) were mainly associated with lower EOI. Inpatients' perceived criticism and outpatients' previous suicide attempts were equally associated with higher criticism and lower EOI (mirror correlations). Finally, various inpatient attributes (older age, chronicity, unemployment and smoking) triggered higher EOI only. Inpatients' age, psychopathology (esp. agitation/aggression and negative symptoms) and perceived criticism survived adjustment for multiple comparisons.

CONCLUSION

Our findings suggest setting-specific pathogenetic pathways of criticism and EOI and might help customize psychoeducational interventions to staff and families.

Family environment and depressive episode are associated with relapse after first-episode psychosis

WHAT IS KNOWN ON THE SUBJECT?: Relapse rates are high among patients who have experienced first-episode psychosis (FEP). Psychotic relapses are associated with worse quality of life and poorer functionality of the FEP patient. The use of psychoactive substances, non-adherence to drug treatment, and high expressed emotion (EE) are notable predictors of relapse after the FEP. Although some studies have suggested that psychotic relapse may be associated with a family environment with high levels of emotional over-involvement (EOI), this finding is still inconsistent across different cultures. EE specific components must be evaluated and interpreted according to the context of cultural norms. There is a scarcity of studies on the role of depression in the occurrence of relapses after the FEP, and the results remain uncertain. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study explored the predictors of psychotic relapses in Brazilian patients who experienced FEP. Our results indicate that 29.2% of the patients relapsed after the FEP. Patients diagnosed with depression and high-EOI in the family environment were predictors of psychotic relapses in this population. This study expands knowledge about the cultural specificity of EOI and the role of depression in psychotic relapse. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nursing professionals must consider the implications of the family environment and depression in the course of psychosis. Family interventions and the appropriate treatment of depression are important for improving the prognosis of FEP patients. ABSTRACT: Introduction Psychotic relapse may be associated with relatives' high emotional over-involvement (EOI) and with a diagnosis of major depressive episode (MDE) among first-episode psychosis (FEP) patients, but the results are still inconsistent across different cultures. Aim Evaluate the predictors of relapse in FEP patients. Method Prospective cohort study with 6-month follow-up conducted with 65 dyads of patients and relatives from an early intervention unit in Brazil. At the baseline interview, relatives answered to a sociodemographic data form and to the Family Questionnaire. Patients provided sociodemographic and clinical data and answered the Measurement of Treatment Adherence; the Alcohol, Smoking and Substance Involvement Screening Test; the Severity of Dependence Scale to assess cannabis dependence, and the MDE module of the Mini-International Neuropsychiatric Interview. Psychotic relapses were evaluated using items from the Brief Psychiatric Rating Scale. The data were analysed using multiple logistic regression. Results 29.2% of the patients presented at least one psychotic relapse. High-EOI and MDE were predictors of psychotic relapses. Discussion Our findings expand the knowledge about the cultural specificity of EOI and the role of depression in psychotic relapse. Implications for practice Family nursing interventions and the appropriate treatment of MDE must be considered in the care of FEP patients.

Predictors of Expressed Emotion in First Episode Psychosis

This article evaluated the predictors of EE and its components, EOI and CC, in relatives of first episode psychosis patients (FEP) in Brazil. Cross-sectional observational study conducted with 82 dyads of FEP patients and their relatives. Data collection instruments: sociodemographic and clinical data questionnaire, Family Questionnaire, Zarit Burden Interview and Morisky Medication Adherence Scale. Logistic and linear regression models were used. Our results indicate that patient's age, relative's sex, daily time spent together, and family burden were predictors of EE and its components. Our findings may be helpful in planning nursing interventions to reduce EE and prevent psychotic relapses.