Influence of family life on the course of schizophrenic disorders: a replication

Caregiver factors influencing family-based treatment for child and adolescent eating disorders: a systematic review and conceptual model

Introduction

The need to assess and manage familial factors influencing family-based treatment (FBT) has been identified in the literature in the context of improving outcomes. While some studies have attempted to address this need, results have not been unified into a framework and to date, no conceptual model exists to bring these factors together for use in clinical practice. A systematic review was conducted to fill this gap and addressed the following question: which caregiver factors influence FBT outcome for child and adolescent eating disorders?

Methodology

The protocol was registered in PROSPERO (CRD42022338843) and utilized the PRISMA framework. A total of 1,994 results were returned from EBSCO Host, Embase, ProQuest, PubMed Central, SCOPUS and Web of Science. Screening returned 164 studies for full-text-review with third-party replication to reduce risk of bias. Thirty-nine articles were included and organized in an evidence hierarchy including both quantitative and qualitative methodologies. Heterogeneity of the data precluded meta-analysis; results were synthesized and grouped using a systematic-narrative approach.

Results

Influential caregiver factors were identified and grouped into eight domains: caregiver capacity, confidence, readiness, internalizing factors, externalizing factors, food-related factors, support network and family function. Factors within each domain and their influence on treatment outcome were reported. A conceptual model, caregiver factors influencing treatment (Care-FIT) was produced as a graphical representation of the identified domains and factors by frequency of appearance.

Conclusion

Caregiver factors can significantly impact FBT outcome, and given the importance of their role in treatment, effective identification and management of caregiver factors is warranted. The conceptual model can be used in clinical case formulation and to support further exploration of the degree to which factors are influential. Identifying caregiver factors likely to influence treatment can facilitate support to enhance treatment and recovery.

Expressed emotion of caregivers to children at familial high risk of schizophrenia or bipolar disorder: The Danish High Risk and Resilience Study - VIA 11

A high level of parental expressed emotion is thought to play an important role in the development and course of mental disorders in offspring. This study investigates expressed emotion among primary caregivers to 11-year-old children at familial high risk of schizophrenia or bipolar disorder and population-based controls, and whether potential differences in expressed emotion are related to child psychopathology. Expressed emotion was assessed with the Five-Minute Speech Sample and a total of 440 audio files from primary caregivers were collected. Child psychopathology was assessed with the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children. Primary caregivers from families with a parental diagnosis of schizophrenia spectrum disorder or bipolar disorder were classified as high on expressed emotion significantly more often than population-based controls. Between-group differences remained significant after adjusting for any current axis I child diagnosis indicating that high expressed emotion is not solely attributable to the presence of child psychopathology. These findings underline the importance of assessing the emotional climate in families with parental schizophrenia and bipolar disorder.

Caregiver burden during psychiatric hospitalisation: A multi-centre, longitudinal study

WHAT IS KNOWN ABOUT THE SUBJECT

Caring for a family member with a mental illness induces a burden on the caregiver, an impact on their quality of life and premature ageing of more than ten years.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

We conducted systematised and individualised nursing interviews with family members, on the first days of a relative's hospitalisation, during hospitalisation and three months after discharge. We observed persistent depressive symptoms during and after hospitalisation. Burden and depression were higher, and quality of life was lower, for women caregivers and when the caregivers admitted the patients involuntarily in the hospital ward. When the caregivers were experiencing a patient's first hospitalisation, we also found higher depressive symptoms and lower quality of life.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

This study emphasises the need for new interventions such as psychoeducation to alleviate the suffering of families. Considering the burden of families could become a prevention objective from the patient's first hospitalisation and prevent them from mental or physical health problems.

ABSTRACT

Introduction The burden consequent to providing care to patients with psychiatric chronic conditions is often overlooked by health professionals. Aim We assessed the impact of patients' psychiatric hospitalisation on their caregivers, through evaluating their suffering, burden and quality of life, in three stages: upon the patients' admission, their discharge and 3 months after their discharge. Method In total, 127 caregivers of adult patients whose first hospitalisation was less than 5 years ago were assessed using the 36-item Short-Form Health Survey, the Zarit Burden Interview and the Center for Epidemiologic Studies Depression scale. Results Females and caregivers who admitted patients against their will experienced higher burden and depression and lower mental quality of life. We also found higher depressive symptoms and lower quality of life among caregivers during a patient's first hospitalisation. The caregiver's familial relationship to the patient was not associated with these outcomes. Finally, burden decreased and quality of life increased over time. Discussion Results suggest that several variables associated with patient hospitalisations were correlated with burden, depression or quality of life. Implications for Practice Burden could be targeted with interventions such as group psychoeducation for caregivers during or after the patient's hospitalisation, in order to reduce their distress and improve their quality of life. Psychiatric and mental health nurses can provide support to caregivers with systematic assessments of their burden and quality of life, so as to better meet their needs and promote their ability to cope with mental illness.

Expressed emotions among caregivers of individuals with schizophrenia and associated factors: a multihospital-based survey in Southern Thailand

BACKGROUND

Schizophrenia is a multifactorial disorder influenced by various biological and psychosocial factors. This study aimed to determine the characteristics and associated factors of expressed emotion (EE) among caregivers of individuals with schizophrenia.

METHODS

From May to July 2024, a cross-sectional study was conducted with caregivers of individuals with schizophrenia across multiple hospitals in Southern Thailand. The study utilized four questionnaires: (1) Demographic inquiry, (2) The Thai Expressed Emotion Scale (TEES), (3) The Thai General Health Questionnaire (GHQ-12), and (4) The Zarit Burden Interview (ZBI). Data were analyzed using descriptive statistics. The groups analyzed were compared using the Analysis of Variance (ANOVA) or Kruskal-Wallis test, the Student t-test or Wilcoxon rank sum test, and the Chi-square test. Multiple logistic regression analysis was performed.

RESULTS

In a survey of 200 caregivers, 70.5% were female. They had a median caregiving duration of 108 months, with an interquartile range (IQR) of 36 to 180 months. Notably, 51.0% of caregivers reported no mental health problems, as assessed by the GHQ-12, while 29.0% indicated experiencing severe burden. The median score on the TEES was 99.0, with an IQR of 84.7 to 109.0. Furthermore, 46.0% of caregivers reported TEES above the median score, indicating high levels of EE. There was also a significant correlation between caregiver burden and EE scores. Those experiencing severe burden had an EE score of 110.5 compared to 94.0 for those with no burden, which was statistically significant (p = 0.001). Multiple logistic regression analysis revealed that high EE among caregivers was associated with factors such as the patient's duration of illness, caregiver occupation, and mental health status.

CONCLUSION

Nearly half of the caregivers of individuals with schizophrenia reported high levels of EE, with increased caregiver burden associated with higher EE levels. Factors such as the duration of the patient's illness, caregiver occupation, and mental health status were also associated with higher EE. Moreover, caregivers' emotional responses and expressions are complex and dynamic. Thus, focusing on providing support to caregivers can have a positive impact on the well-being of both caregivers and individuals with schizophrenia.

The TIPS family psychoeducational group work approach in first episode psychosis and related disorders: 25 years of experiences

AIM

The aim of this paper is to present 25 years of clinical experience with family psychoeducation (FPE) work at Stavanger University Hospital in Norway, highlighting the lessons learned in overcoming implementation barriers in publicly funded specialized mental health care.

METHODS

This retrospective analysis reviews the integration and sustainability of FPE work within the hospital's standard treatment protocols for psychosis, tracing its origins from the Early Treatment and Intervention in Psychosis (TIPS) study (1997-2000) to its current application. The paper examines key strategies for successful implementation, including staff training and resource allocation, as emphasized by international research.

RESULTS

Stavanger University Hospital has successfully implemented and maintained both multi- and single-family FPE approaches over the past 25 years. Initially part of the TIPS study, FPE has been integrated into routine clinical practice for treating psychosis and has recently been extended to families of patients with other severe mental disorders. The sustained success at Stavanger University Hospital is attributed to consistent staff training and the prioritization of sufficient resource allocation.

DISCUSSION

The successful and sustainable integration of FPE at Stavanger University Hospital is relatively unique. International guidelines recommend FPE for psychosis, but its implementation remains inconsistent globally, despite over 50 years of supporting evidence. The hospital's experience underscores the critical role of continuous training and dedicated resources in embedding FPE into regular clinical practice. These findings suggest that addressing these areas can significantly enhance the uptake of FPE in other clinical settings.

CONCLUSION

The 25-year experience at Stavanger University Hospital demonstrates that with appropriate training and resources, FPE can be successfully integrated and sustained within standard mental health care practices. This case study provides valuable insights for other institutions aiming to implement FPE and improve treatment outcomes for patients with severe mental disorders.

Perceived expressed emotion in individuals with a first episode of psychosis from a south Asian background

AIM

To explore perceived expressed emotion in the south Asian context for individuals with a first episode of psychosis (FEP).

METHOD

Semi-structured interviews were conducted with 16 service users experiencing a FEP to understand their experience of expressed emotion (EE) from their caregivers. Interviews were analysed using inductive thematic analysis.

RESULTS

Four main categories were identified: connection and support, understanding and awareness, boundaries and independence and context and influence. Factors influencing perceived expressed emotion such as acceptance, acculturation, warmth and expressions of love, communication and family values were identified. Findings highlight south Asian's experiences of being cared for, and their perception of EE, including warmth and connection as a strength and resource.

CONCLUSION

The findings shed light on culturally specific EE within the context of FEP that can be considered when working with south Asian communities within early intervention services. Findings highlight the impact of navigating and negotiating bicultural identities and generational differences in EE in the British south Asian context.

Influential Relationship Questionnaire (IRQ): psychometric characteristics of an abbreviated Spanish version

BACKGROUND

The relevance of family relationships in the outcome of various disorders has been highlighted from different domains. Specifically, empirical studies on the relationship between the outcome of schizophrenia and various affective dimensions of family relationships have allowed the identification of particularly relevant aspects: criticism, hostility, and over-protection.

AIMS

The present study aims to adapt and validate an abbreviated Spanish version of the Influential Relationship Questionnaire (IRQ), an instrument that measures the patient's own perception of the affective dimensions of family relationships.

METHOD

Participants were 188 patients (63.8% male) of the Public Health Service in Andalusia (Spain) with a diagnosis of schizophrenia or a related disorder. One hundred and thirty-six participants provided data related to both father and mother, and 52 only related to mother or father, so the analyses were carried out with a total of 324 questionnaires. Simultaneously, in 130 participants, the Perceived Criticism Scale was applied, and in 50 cases, relatives were asked to complete the Family Attitudes Scale.

RESULTS

Principal component analysis allowed for the identification of four factors that explained 61.53% of the total variance (criticism, over-protection, restriction, and care). The values of Cronbach's alpha coefficient, as well as the omega coefficient, showed high consistency. The temporal reliability for an interval of 3 months was high. The correlations between the IRQ dimensions and the other variables included in the study were significant and in the expected direction.

CONCLUSIONS

The results support the reliability and validity of the abbreviated version of the IRQ.

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.

Mindfulness-based family psychoeducation intervention for caregivers of young adults with first-episode psychosis: results at 9-month follow-up

Objectives

To investigate the effects of a mindfulness-based family psychoeducation (MBFPE) intervention on caregivers and the young adults with first-episode psychosis in mental health care.

Methods

Sixty-five caregivers were randomly assigned to the MBFPE program (n = 33) or an ordinary family psychoeducation (FPE) program (n = 32). Eighteen young adults in recovery (YAIR) also participated in the study. All of the participants completed the assessments before participating in the intervention (T1), after the intervention (T2), and at 9-month follow-up (T3).

Results

Intention-to-treat analyses were conducted. The caregivers reported a significant and large effect size on positive caregiving experiences based on a Time × Group analysis (g = 0.862, p = 0.006). Among the YAIR participants, between-group differences were significant in their perceptions of caregivers' expressed emotions, including large effect sizes of perceived criticism (g = 1.396, p = 0.049) and hostility (g = 1.444, p = 0.043). Caregiver demographics, including age, education level, socioeconomic status, and number of family members, were found to moderate the effect sizes of the variables studied.

Conclusion

This study provides evidence of the effects of MBFPE programs on the outcomes of caregivers and the young adults with first-episode psychosis in their care. Specifically, the MBFPE program in this study played a greater role in promoting positive caregiving experiences and changing caregivers' expressed emotions, especially their expressed criticism of YAIR, compared with the regular FPE program. Therefore, the application of mindfulness training to promote family care and YAIR recovery should be encouraged.

Clinical trial registration

ClinicalTrials.gov, identifier NCT03688009.

Dyadic effects of stigma on quality of life in people with schizophrenia and their family caregivers: Mediating role of patients' perception of caregivers' expressed emotion

Schizophrenia, as a stressful diagnosis, profoundly impacts the whole family, especially people with schizophrenia and their caregivers. This study tested the potential mediating role of expressed emotion in the association between mental health stigma and quality of life in caregiver-patient dyads. Using a 2-wave longitudinal design with a 6-month interval between assessments, 161 dyads of patients with schizophrenia and their family caregivers (one patient and one caregiver) completed measures of mental health stigma, expressed emotion, and quality of life. The results showed that patients' self-stigma had no significant actor or partner effect on expressed emotion or quality of life. In contrast, caregivers' stigmatizing attitudes toward patients had a significant partner effect on patients' perception of caregivers' expressed emotion and quality of life. The mediating effect of patients' perception of caregivers' expressed emotion in the association between caregivers' stigmatizing ideas toward patients and patients' quality of life was significant. By focusing on the interdependence of patients and their caregivers, this study highlights the role of caregivers' stigmatizing attitudes toward patients and patients' perception of caregivers' expressed emotion on patients' quality of life. Psychoeducation and interventions should not only aim to reduce the self-stigma of people with schizophrenia but also their caregivers' stigmatizing ideas toward patients. Family interventions targeted at reducing the EE level of caregivers and patients' perception of caregivers' EE would also benefit the adaptation and quality of life of people with schizophrenia and their caregivers.

Automatic detection of expressed emotion from Five-Minute Speech Samples: Challenges and opportunities

Research into clinical applications of speech-based emotion recognition (SER) technologies has been steadily increasing over the past few years. One such potential application is the automatic recognition of expressed emotion (EE) components within family environments. The identification of EE is highly important as they have been linked with a range of adverse life events. Manual coding of these events requires time-consuming specialist training, amplifying the need for automated approaches. Herein we describe an automated machine learning approach for determining the degree of warmth, a key component of EE, from acoustic and text natural language features. Our dataset of 52 recorded interviews is taken from recordings, collected over 20 years ago, from a nationally representative birth cohort of British twin children, and was manually coded for EE by two researchers (inter-rater reliability 0.84-0.90). We demonstrate that the degree of warmth can be predicted with an F1-score of 64.7% despite working with audio recordings of highly variable quality. Our highly promising results suggest that machine learning may be able to assist in the coding of EE in the near future.

State of the art in psychological therapies for psychosis: Family interventions for psychosis

PURPOSE

It is a half-century since the coalescence of social psychiatry and systemic family therapy approaches started to inform condition-specific therapeutic work with families to reduce relapse and hospital readmission for people with schizophrenia. Today, family interventions are a cornerstone of international guidelines for the treatment of psychosis, and of workforce development initiatives. Effect sizes for clinical and economic outcomes are large, and the evidence base is robust and reliable, not only for outcomes but also for the underpinning theoretical models, which are coherent and consistent. Few, if any, psychological therapies, have so powerful a framework to drive widespread implementation. Nevertheless, delivery in clinical services is variable, often lagging behind that of individual cognitive behavioural therapy, notwithstanding its considerably weaker implementation framework. Our aim in this article is to formulate this translation failure and offer potential solutions.

METHOD

We summarise the model/intervention and supporting evidence, then consider why delivery remains problematic.

RESULTS

We highlight the inter-linked issues of conceptual confusion between and conflation of, different approaches to working with families; of addressing diagnostic uncertainty, complex comorbidity and adapting interventions for specific populations; and of translation from gold-standard research trial practice, through educational curricula and training programmes, to routine delivery in frontline services.

CONCLUSION

We present our view of clinical, research and workforce development priorities to address these issues and continue the collective effort, moving into the next half-century, to work more effectively with people with psychosis and their families, to further improve outcomes.

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.

Assessing the Educational Needs of Family Caregivers of Psychiatric Patients in Jeddah, Saudi Arabia

Background Family caregivers of psychiatric patients in Saudi Arabia and most of the Eastern world are suffering a big burden as a result of their caregiving role. Aim This study aims to assess the need for psychoeducation for family caregivers of psychiatric patients from outpatient clinics in a psychiatric hospital in Jeddah, Saudi Arabia. Materials and methods A cross-sectional descriptive-analytical study was conducted, which included a total of 379 family caregivers providing care to a patient suffering from a psychiatric illness. Results The majority of family caregivers looking after a patient suffering from a psychiatric illness were a brother or sister (20.8%), followed by a son or daughter (20.6%), and lastly, a spouse (10.3%). The top 10 important educational needs of the caregivers included their desire to know about the daily treatment of the patient, followed by how to improve social relationships, and a need for effective stress management. Family caregivers also showed interest in stress and illness. The caregivers' areas of least concern were about the admission of the patients to psychiatric hospitals, recent research on mental illnesses, and how to deal with weight gain. Conclusion The study showed that caregivers demonstrated a need for more experience in how to care for psychiatric patients. Indeed, this has an interrelated impact on the general well-being of both the patient and the caregiver. The study recommends the need for care guidelines to be provided by hospitals from the patient's education department for caregiving to help the family in their daily care.

Expressed Emotion in Families of People With Dementia: A Review of Scale-Based Measures

PURPOSE

Research on the concept of expressed emotion (EE) has expanded in recent years but its role in dementia still requires elucidation. Understanding the role of EE in the dementia context could help in the development of appropriate interventions.

METHOD

The current review synthesized relevant literature to investigate the prevalence and correlates of EE status in families of people with dementia. A comprehensive search of four databases from inception to 2022 produced 2,683 papers; 18 studies met inclusion criteria.

RESULTS

The use of EE criteria differed not only across cultural contexts, but even within the same cultural context. Overall, the prevalence of EE in families with dementia compared with other psychiatric conditions was not high.

CONCLUSION

Specific changes in EE over time remain to be explored, and findings emphasize the need to carefully discriminate High EE status based on the cultural background of family members with dementia. [Journal of Gerontological Nursing, 50(2), 17-25.].

Expressed emotion in the South Asian diaspora living in the UK: A qualitative study

BACKGROUND

'Expressed Emotion (EE)' captures ways in which emotions are expressed within a family environment. Research has found that EE in families has an impact on psychiatric illness, in particular psychosis, such that it increases risk of relapse. EE was conceptualised by research conducted in the UK. Thus, behaviours defined as pathological were largely based on white samples adhering to UK norms. Cross-cultural variations have been found in EE and its relationship with clinical outcomes. A more culturally appropriate understanding of norms surrounding the EE across cultures is required.

AIMS

This study aims to use a bottom-up approach to provide a culturally specific understanding of family relationships and EE across 'non-clinical' UK-based South Asian families.

METHODS

Semi-structured interviews were conducted with 18 South Asian participants to explore their relationships with a significant other. Interviews were analysed using thematic analysis.

RESULTS

Four main themes were generated: expression of love, setting boundaries, inter-generational differences and acceptance.

CONCLUSION

The findings indicate considerable cultural variability within EE and highlight the need to interpret EE in the context of socio-cultural norms. Whilst certain domains of EE that are considered pathological in Western contexts are present in the UK-based South Asian diaspora, these are perceived as less problematic, indicative of varying cultural norms.

The comparison of expressed emotion of parents of individuals with fragile X syndrome to other intellectual disabilities

BACKGROUND

Parenting children and young adults with intellectual disabilities, including individuals with fragile X syndrome and Down syndrome, is challenging, joyful, and complicated. Exploring how parents talk about their children, and the quality of the parent/child relationship can provide insight into the home environment and interactional patterns of the family.

METHOD

Expressed emotion (EE) is a measurement of a family's emotional climate based on a parent or caregiver's report of warmth, emotional overinvolvement, hostility, and criticism. The purpose of this study was to describe EE for a sample of parents of individuals with intellectual disabilities and to determine any differences in EE amongst individuals within subgroups. Based on previous research about fragile X syndrome and family systems, we hypothesized that there would be significant differences between the disability groups (higher EE in families with children/young adults with fragile X syndrome).

RESULTS

Results showed relatively high proportions of EE across groups of individuals with intellectual disabilities, however, there were no significant differences between the subgroups. Null findings suggest that differences in EE may not relate directly to a child's specific genetic condition. Rather, increased EE in caregiver populations may simply reflect well-documented stressors related to stigma, caregiver burden, and limited community supports. Critical statements were infrequent, however, over half of the participants reported dissatisfaction with their situation, and many were categorized as having emotional overinvolvement, as measured by frequent statements of intense worry and self-sacrifice.

CONCLUSION

Findings point to potential utility in family-level interventions focused on providing structured caregiver therapy to manage excessive worry and grief related to a diagnosis of intellectual disability, and respite care to encourage caregiver independence and pursuit of personal care.

Expressed emotion and treatment outcome in higher levels of care for eating disorders

OBJECTIVE

Expressed emotion (EE) among caregivers toward the affected offspring is a negative prognostic indicator for adolescent patients with eating disorders (EDs) in outpatient treatment. Less research has examined its impact on adolescents in higher levels of care (HLOC). The current study examined differences in caregiver EE according to the subtype of anorexia nervosa (AN) (restricting [AN-R] versus binge/purge [AN-BP]), and level of care (LOC). We also examined the main effects of baseline caregiver EE (emotional overinvolvement [EOI] or criticism), AN subtype, and their interaction on eating pathology and depression at discharge.

METHOD

Adolescent patients (N = 203) receiving treatment at HLOCs completed measures of ED pathology (Eating Disorder Examination-Questionnaire) and depression (Patient Health Questionnaire-9) at baseline and discharge, and one caregiver of each patient completed a measure of EE (Family Questionnaire) at baseline.

RESULTS

No differences in caregiver EE were found between patients with AN-R versus AN-BP, or relative to LOC. Caregiver EE did not predict outcome for ED symptoms or depression at discharge.

DISCUSSION

The impact of high caregiver EE may be less substantial at HLOCs than outpatient care given that caregivers are less involved in treatment at HLOCs. Future research is needed to determine if high caregiver EOI leads to poor treatment outcome for adolescents as it does for adults, or whether it is an appropriate expression of care for patients who are ill enough to require HLOC treatment.

PUBLIC SIGNIFICANCE STATEMENT

High caregiver EE was not found to predict treatment outcome for adolescents with eating disorders in higher levels of care (HLOCs), possibly due to the limited involvement of caregivers in HLOCs. However, patients step down to outpatient treatment, where high caregiver EE can have a significant negative impact on outcome. HLOCs should incorporate efforts to reduce high caregiver EE in anticipation of step-down to outpatient treatment.

The Structure of Temperament in Caregivers of Patients with Schizophrenia

The onset of schizophrenia symptoms usually occurs in early youth. As a result, the parents of these patients usually become their caregivers. The role of a caregiver for a person with schizophrenia is a considerable mental and physical burden. Therefore, an interesting issue is what motivates these people to take up this challenge. It is probable that, apart from the moral imperative or kinship, the factor determining this decision is the personality structure of the caregiver. The aim of our study was to compare the structure of temperament (according to the model of temperament as formal characteristics of behavior developed by Jan Strelau) in caregivers of young adults (age 18-25 years) with schizophrenia with the structure of temperament of parents of healthy young adults still living in the family home under their care. The study group consisted of 64 people (51 women), who were taking care of young adults (aged 18-25 years) with schizophrenia, while the control group (53 people, 42 women) consisted of parents of healthy adults still living in the family home. Both groups were asked to complete a questionnaire of the authors' own design on their demographic data as well as The Formal Characteristics of Behavior-Temperament Inventory to assess the temperament traits. The results were given in the number of points obtained on average in each dimension. Both groups did not differ in terms of size and age, with women predominating. Caregivers of young adults with schizophrenia had higher values of briskness (43.22 ± 4.45 vs. 42.90 ± 3.98, p = 0.032), emotional reactivity (46.02 ± 4.39 vs. 41.01 ± 3.12, p = 0.012) and activity level (44.01.89 ± 4.15 vs. 37.59 ± 4.77, p = 0.022) compared to the control group. The remaining dimensions of temperament: perseverance, sensory sensitivity, rhythmicity, and endurance did not differentiate between the two groups. The temperament structure of caregivers of young people with schizophrenia differs from the temperament structure of caregivers of healthy adults. Caregivers of sick people have higher values of briskness, emotional reactivity, and activity level compared to the control group.

Motivational interviewing for loved ones: Randomized controlled trial of brief training for first episode psychosis caregivers

BACKGROUND

Research shows that family involvement in psychosis treatment leads to better patient outcomes. Interventions that involve and counsel family members may improve patient outcomes by addressing barriers to treatment adherence and lowering family expressed emotion, thereby creating a less stressful and more supportive home environment. Learning to use motivational interviewing communication skills may help caregivers to decrease conflict and expressed emotion and improve treatment adherence.

METHODS

The current study is a pilot randomized controlled trial testing the impact of "Motivational Interviewing for Loved Ones" (MILO), a brief five-hour psychoeducational intervention for caregivers, in a sample of family members of individuals with early course psychosis (N = 40). Using a randomized crossover design, caregivers were randomized to either immediate MILO or a six-week waitlist control condition; all participants eventually received the intervention.

RESULTS

Caregiver participants experienced large (d = 1.08-1.43) and significant improvements in caregiver wellbeing, caregiver self-efficacy, family conflict, and expressed emotion. There was no change over time in caregiver-reported patient treatment adherence. Relative to waitlist, MILO had significant effects on family conflict and expressed emotion, a trending effect on perceived stress, and no effect on parenting self-efficacy or treatment adherence.

CONCLUSIONS

MILO showed benefits for caregivers of FEP patients in this small, controlled trial. Further testing in a larger randomized controlled trial is warranted to better characterize MILO's effects for caregivers and patients across a range of diagnoses.

Using Photovoice in a Mindfulness-Based Program to Understand the Experiences of Caregivers of Young Adults with Psychosis

Studies have consistently shown that family caregivers experience caregiver burden and depression when they provide care for family members with psychosis. Photovoice is a participatory action research method of fostering dialogues about personal experiences by sharing and discussing photographs that may improve our understanding about how a mindfulness-based family psychoeducation program (MBFPE) can reduce the caregiver burden and improve their caregiving experience. We explored the experiences of the participants in their use of photovoice in a MBFPE. We investigated whether the MBFPE program generated positive changes for caregivers of young adults with psychosis. Using photovoice, we collected qualitative data to help develop a unique contextual understanding of MBFPE program outcomes and generate novel ideas, insights, suggestions, and questions on the basis of participant's perceptions. Participants in our pilot study and randomized controlled study of MBFPE were invited to participate in this photovoice activity. On the basis of a procedure developed for MBFPE, caregivers were invited to use photographs to express how mindfulness contributed to caregivers' management of their caregiving stress and burden. Caregiver's inquiry with the MBFPE instructors were transcribed for analysis together with the photographs. A grounded theory approach was adopted to analyze the photovoice images, participants' reflections, and inquiries of photographs. Six themes were developed in understanding the lived experience of caregivers in participation of MBFPE: (1) I pay attention to the present moment; (2) I care about my family; (3) I trust my children; (4) I appreciate the connection with and support from nature and the universe; (5) I observe my worries and guilt and learn not to be reactive; and (6) I find space in offering care and exercising self-care. The application of photovoice can offer an additional approach to enhance the awareness and insights of participants in a mindfulness-based program. Specific guidelines may be developed to enhance the learning of participants.

Treatment-engagement fears in family-oriented interventions: validation of the caregiver traps scale for eating disorders

As more caregivers of children (of any age) struggling with an eating disorder are recruited as partners in care, it is important to identify potential barriers to such involvement. The Caregiver Traps Scale for Eating Disorders (CTS-ED) was developed as a measure of caregiver fears with respect to treatment-engagement. The purpose of this study was to evaluate its psychometric properties. One hundred and twenty four parents of children with ED participated in the validation of this instrument. Data were analyzed through exploratory factor analysis. The exploratory factor analysis revealed one factor, accounting for 39% of the variance, with a mean of 3.99 (scale from 1 to 7), indicating that caregivers endorsed clinically significant fears relating to their involvement in their child's treatment. The scale yielded high internal consistency (α = .89). As expected, the CTS-ED was significantly positively correlated with a measure of accommodating and enabling of ED symptoms, and negatively correlated with a measure of parental self-efficacy. This scale shows promise as a measure for clinicians and researchers to identify parental fears that could potentially fuel accommodating, enabling or treatment-interfering behaviors. Suggestions for its utility as a clinical and supervision tool are also provided.Clinical SignificanceDevelopment of an assessment tool to identify caregiver fears with respect to therapy engagement in the context of family-oriented interventions for eating disordersTool has the potential to increase the positive involvement of caregivers to support their child (of any age) with an eating disorderTool can be used clinically and to support self-reflective practices to improve compassionate clinician engagement of caregivers struggling to support their child.

High Expressed Emotion and Warmth among Families of Patients with Schizophrenia in Greece

Expressed emotion (EE) is an established prognostic factor for relapse in schizophrenia. Through critical comments (CC), hostility (H) and emotional overinvolvement (EOI), a relative can be rated as high or low EE, but the role of warmth should also be evaluated in order to consider the influence of a positive affect within the family context. In this study, EE was assessed in a sample of 48 relatives of patients with schizophrenia using the Camberwell Family Interview (CFI). Questionnaires assessing coping (brief-COPE), their wellbeing (World Health Organization Well-Being Index WHO-5) and the socio-demographic variables were also administered. Relatives who expressed a higher level of warmth were found to make fewer CC (5.2 ± 4.6 vs. 8.4 ± 4.6, p = 0.009) and have, on average, higher EOI scores (3.2 ± 1.0 vs. 1.9 ± 1.1, p = 0.002) than those who expressed no or very little warmth. High EE was found to be associated with having fewer family members (p = 0.035), while relatives with a higher level of education expressed less warmth (p = 0.007). Relatives with a low level of warmth had higher maladaptive coping scores and tended to score worse for their overall wellbeing in comparison to relatives who showed a higher level of warmth (28.4 ± 5.0 vs. 24.1 ± 5.2, p = 0.006 and 39.1 ± 20.4 vs. 51.3 ± 22.0, p = 0.073, respectively). Since the role of warmth is important, it should be taken into account when designing family interventions, independently from lowering EE. Customized interventions to promote warmth and the routine screening of relatives are recommended.

Do attachment-related differences in reflective functioning explain associations between expressed emotion and youth self-harm?

Youth self-harm is associated with poor health outcomes and attempted and completed suicide. Associations exist between self-harm and expressed emotion (EE), attachment insecurity, and reflective functioning (RF), but these associations are poorly understood. This study evaluates a mediation model in which perceived caregiver EE (pEE) exerts an indirect effect on youth self-harm through attachment insecurity and RF uncertainty. 461 participants aged 16-24 years completed an online survey. Statistical analyses revealed significant direct effects of pEE on attachment insecurity, and of RF uncertainty on self-harm; however, some direct effects were specific to pEE from female caregivers, and attachment insecurity in youth relationships with female caregivers. A significant direct effect of pEE on self-harm was found for pEE from male caregivers only. Significant indirect effects of pEE on self-harm through attachment anxiety and RF uncertainty were found only in relation to female caregivers. The findings encourage family-, attachment-, and mentalization-based approaches to preventing and treating youth self-harm, with a recommendation that caregivers are given adequate support, education, and skills-based training following youth disclosures of self-harm.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12144-022-03614-w.

A scoping review of non-specific predictors, moderators, and mediators of family-based treatment for adolescent anorexia and bulimia nervosa: a summary of the current research findings

PURPOSE

This scoping review presents an up-to-date synthesis of the current evidence base for non-specific predictors, moderators, and mediators of family-based treatment (FBT) for adolescent anorexia and bulimia nervosa.

METHODS

We identify ways in which end-of-treatment outcomes have been shown to differ based upon baseline clinical features and person-specific factors and explore psychological mechanisms that may explain differences in treatment response. We draw from this evidence base to outline recommendations for clinical practice, as well as directions for future clinical eating disorder research.

RESULTS

Noted findings from review include that early response in weight gain and parental criticism may be particularly influential in treatment for anorexia nervosa. Further, for adolescents with either anorexia or bulimia nervosa, eating-related obsessionality may be a key intervention target to improve outcomes.

CONCLUSION

In addition to highlighting a need for attention to specific patient- and caregiver-level factors that impact treatment response, recommendations for research and clinical practice include testing whether certain targeted treatments (e.g., exposure-based approaches) may be suitable within the context of FBT for eating disorders.

LEVEL OF EVIDENCE

Level I: Evidence obtained from: at least one properly designed randomized controlled trials; experimental studies.

Expressed Emotion and Health Care Use in Borderline Personality Disorder Patients and Relatives

Introduction: Expressed emotion (EE) is a global index of attitudes, emotions, and behaviors of relatives who have family members with a mental or psychiatric disorder. The objective of this cross-sectional study was to study EE in relatives and patients’ perceived EE in a borderline personality disorder (BPD) outpatient sample. Methods: The sample was composed of 134 relatives and 111 BPD outpatients who were receiving psychological treatment. Relevant clinical outcomes, number of medical visits, EE in relatives and perceived EE in BPD patients were measured. Subsequently, descriptive statistical analyses, dependent-samples t tests, and correlation analyses were performed. Results: Relatives' EE was not significantly different than patients' perceived EE. Expressed emotion factors were weakly associated to emergency department visits and hospital admissions. Discussion: Contrary to EE studies in other diagnoses, results show that the BPD patients' emotional climate in their proximate relationships might not influence health care use.

Psychological Treatments for Psychosis: History and Overview

This article is part of the ISPS (International Society for the Psychological Treatment of the Schizophrenias and other Psychoses) task force report on the PORT (Patients Outcome Research Team) recommendations for treatment of schizophrenia. It reviews psychological treatment approaches in psychosis to date and assesses recent trends. The most influential therapies have been psychoanalytic/psychodynamic, cognitive behavioral (CBT), and supportive therapy.

Family interventions for relapse prevention in schizophrenia: a systematic review and network meta-analysis

BACKGROUND

Family interventions are efficacious for relapse prevention in schizophrenia. Multiple different models have been developed. We aimed to compare the efficacy, acceptability, and tolerability of family interventions for relapse prevention in schizophrenia.

METHODS

In this systematic review and network meta-analysis, we searched for randomised controlled trials that investigated family intervention models aimed at preventing relapse in patients with schizophrenia. We searched EMBASE, MEDLINE, PsycINFO, BIOSIS, CENTRAL, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform up to Jan 20, 2020 and PubMed up to July 15, 2021. We included blinded and open-label randomised controlled trials in which at least 80% of patients had schizophrenia spectrum disorders. We excluded studies in which all patients were acutely ill, had a concurrent medical or psychiatric disorder, or were prodromal or "at risk of psychosis". Study selection and data extraction were done by two independent reviewers. Data were extracted about overall, positive, negative, and depressive symptoms of schizophrenia, quality of life, adherence, overall functioning, family burden, expressed emotion, and discontinuations due to inefficacy. The primary outcome was relapse, measured with operationalised criteria, psychiatric hospital admissions, or clinical judgement. We did a frequentist, random-effects, network meta-analysis to calculate odds ratios ([ORs]; dichotomous outcomes) or standardised mean differences (continuous outcomes) with 95% CIs. The study protocol was registered with PROSPERO, CRD42020169951.

FINDINGS

We identified 28 395 studies through the database search and 334 from references of previous studies. We compared 11 family intervention models tested on a total of 90 randomised controlled trials with 10 340 participants (3579 females and 5632 males with sex indicated; median age 31 years [range 14-65]) in the network meta-analysis. Ethnicity data were not available. All interventions, with the exception of crisis-oriented interventions and family psychoeducation with two sessions or fewer, reduced the relapse rate significantly when compared with treatment as usual at the primary timepoint of 12 months. ORs compared with treatment as usual ranged from 0·18 (95% CI 0·12-0·27) for family psychoeducation alone to 0·63 (0·42-0·94) for community-based interventions involving family members. The results were robust in various sensitivity and subgroup analyses. The confidence in the estimates ranged from moderate to very low for different comparisons.

INTERPRETATION

Almost all family intervention models were efficacious in preventing relapse in schizophrenia. Family psychoeducation alone, without behavioural or skills training, was superior to the more complex models. Our results suggest that in contexts where there are financial constraints, family psychoeducation alone should be implemented.

FUNDING

German Ministry for Education and Research.

Self-Stigma, Mental Health and Healthy Habits in Parent of Children with Severe Mental Disorder

BACKGROUND

Family members who have children with Severe Mental Disorder under their care have a hard impact on them as they are faced with the task of attending to their demands and care. This is a change in their lives as it significantly interferes with their physical and social well-being. The aim of this study was to explore the relationships between self-stigma, depression, stress and anxiety and their relationship with healthy habits, such as sport and a healthy diet.

METHODS

The sample consisted of 538 parents aged between 38 and 52 years (M = 43.42; SD = 13.11). The parents have children with a diagnosis of mental disorder under their care. Participants completed the Spanish adaptation of the Self-Stigma in Relatives of people with Mental Illness (SSRMI), the Depression, Anxiety and Stress Scale (DASS-21), the Kidmed Scale and the WHO scale, whose responses were analysed using structural equation modelling.

RESULTS

The results showed that self-stigma was positively related to anxiety, stress and depression and, in turn, these three variables were negatively related to sporting activity and healthy eating.

CONCLUSION

This study, therefore, is further evidence of the impact of self-stigma at the physical and mental level on family members, which highlights the need to provide them with support tools and resources, and to work on raising social awareness of mental disorders.

Family functioning and personal growth in Italian caregivers living with a family member affected by schizophrenia: Results of an add-on study of the Italian network for research on psychoses

To date, the role of family members in caring for relatives affected by schizophrenia has focused largely on the negative aspects of impact of the illness. The present study aimed to: (1) assess family functioning and burden of care in caregivers living in Northern, Central, and Southern Italy who looked after subjects affected by chronic schizophrenia; (2) evaluate the relationship between aspects of family functioning and burden of care, in particular personal growth (PG) of caregivers; and (3) identify variables capable of affecting PG of caregivers. A total of 136 caregivers (mean length of illness of family member more than 20 years) were recruited from 9 Italian research sites and evaluated in terms of "positive" family functioning-problem-solving, communication skills and personal goals Family Functioning Questionnaire (FFQ), burden of care, and PG Family Problems Questionnaire (FPQ). Caregivers reported an overall good family functioning with a relatively low objective and subjective burden of care. The latter was positively correlated with length of illness, with women showing a higher subjective burden than men. Reduced problem-solving skills and ability of each family member to pursue personal goals were both associated with reduced objective and subjective burden which, conversely, were both increased by inadequate support and scarce positive comments from relatives and friends. Approximately 50% of caregivers stated that "they had learned something positive from the situation," highlighting a statistically higher proportion of caregivers in southern Italy than in northern and central Italy. Caregivers' PG was associated with good family functioning, adequate professional support, and positive comments. PG also seemed to be positively influenced by support from relatives and friends (O.R. 14.306). The numerous challenges and positive aspects associated with caregiving should be duly acknowledged by mental health services and integrated into routine clinical assessment and intervention framework.

Caregivers' burden and schizophrenia patients' quality of life: Sequential mediating effects of expressed emotion and perceived expressed emotion

BACKGROUND

Increasing attention has been paid to the role of caregivers' burden in affecting quality of life (QoL) of schizophrenic patients. However, less is known about potential mediation mechanisms underlying this relationship. The current study aimed to explore the sequential mediating effect of expressed emotion and perceived expressed emotion on the relationship between care burden and QoL among people with schizophrenia.

METHODS

135 Chinese families (one patient and one caregiver) participated in this study. Caregivers reported their care burden and expressed emotion, patients reported their perceived expressed emotion and QoL.

RESULTS

The results of the correlation analysis showed that care burden was negatively related to patients' QoL, including physical, psychological, and social relationships domains, with patients' sex, age, educational level, employment status, and medication-taking as covariates. The sequential mediating effects of criticism and perceived criticism between care burden and QoL were not significant. However, the sequential mediating effects of emotional over-involvement and perceived emotional over-involvement (EOI) between care burden and QoL (including physical and psychological domain) were significant.

CONCLUSION

The results indicated that reducing the burden and expressed emotion of caregivers could be helpful to improve schizophrenia patients' QoL.

Hydrogeochemical Assessment of Groundwater and Suitability Analysis for Domestic and Agricultural Utility in Southern Punjab, Pakistan

Groundwater is a critical water supply for safe drinking water, agriculture, and industry worldwide. In the Khanewal district of Punjab, Pakistan, groundwater has severely deteriorated during the last few decades due to environmental changes and anthropogenic activities. Therefore, 68 groundwater samples were collected and analyzed for their main ions and trace elements to investigate the suitability of groundwater sources for drinking and agricultural purposes. Principal component analysis (PCA) and cluster analysis (CA) were employed to determine the major factors influencing groundwater quality. To assess the groundwater’s appropriateness for drinking and irrigation, drinking and agricultural indices were used. The pH of the groundwater samples ranged from 6.9 to 9.2, indicating that the aquifers were slightly acidic to alkaline. The major cations were distributed as follows: Na+ > Ca2+ > Mg2+ > K+. Meanwhile, the anions are distributed as follows: HCO3− > SO42− > Cl− > F−. The main hydrochemical facies were identified as a mixed type; however, a mixed magnesium, calcium, and chloride pattern was observed. The reverse ion exchange process helps in exchanging Na+ with Ca2+ and Mg2+ ions in the groundwater system. Rock weathering processes, such as the dissolution of calcite, dolomite, and gypsum minerals, dominated the groundwater hydrochemistry. According to the Weight Arithmetic Water Quality Index (WAWQI), 50% of the water samples were unsafe for drinking. The Wilcox diagram, USSL diagram, and some other agricultural indices resulted in around 32% of the groundwater samples being unsuitable for irrigation purposes. The Khanewal’s groundwater quality was vulnerable due to geology and the influence of anthropogenic activities. For groundwater sustainability in Khanewal, management strategies and policies are required.

[Involuntary admission to psychiatry at the request of caregivers: The point of view of caregivers]

OBJECTIVES

In France, the family and friends of a patient with a psychiatric disorder can legally be involved in the decision to involuntary admission to psychiatry through care at the request of a third party. This involvement has been questioned in recent years, notably to protect this third party. The main objective of this work was to assess whether providing the third party with information on care without consent when providing care at the request of a third party (SDT) had an impact on the third party's experience. The secondary objectives were to identify other factors that might impact the third party's experience of the SDT, and to assess the impact of the SDT on the relationship between the third party and his or her hospitalized relative, as well as the factors that might influence it.

METHODS

The study was based on a questionnaire, constructed after meeting several members of an association of relatives of patients with psychiatric disorders : UNAFAM. This questionnaire questioned the context of hospitalization, the information provided concerning care without consent, the experience of the third party at the time of hospitalization and at a distance, and the impact of hospitalization on the relationship between the third party and his or her hospitalized relative, both at the time of hospitalization and at a distance. This questionnaire was then sent to UNAFAM members in three randomly selected regions. It was specified that it was only intended for people who had already been a third party during SDT. The results were received anonymously.

RESULTS

Among the 166 respondents, 85 (51.2 %) had received information about involuntary admission, and there was more frequent relief at the time of hospitalization (P<0.01) and at a distance (P<0.01), and less frequent feelings of violence towards their loved one at a distance from hospitalization (P=0.02) compared to those who had not received information. The negative impact of hospitalization on the relationship between the third party and their hospitalized relative was lower (P=0.04) among third parties who received information. The fact that the doctor was perceived as being mainly responsible for the decision to hospitalize also preserved the third party's experience and relationship with his or her relative. However, third parties who understood their involvement as an administrative necessity reported less frequent relief (P=0.01), and the negative impact of hospitalization on their relationship with their relative was higher (P=0.01). Conversely, the fact that they felt integrated into the care and listened to by the health care team was correlated with a better experience of the situation by the third party, and a lesser negative impact of hospitalization on the relationship between the third party and their relative.

CONCLUSIONS

Providing information to the third party about involuntary admission at the time of an SDT could improve his or her experience of the situation and limit the negative impact of hospitalization on his or her relationship with his or her loved one. Although it seems important for the third party to feel that the majority of the decision to hospitalize is made by the physician, including him/her in this decision could improve his/her experience of the situation and limit the negative impact of hospitalization on the relationship between the third party and his/her family member.

Expressed emotion and long-term outcome among adolescents with anorexia nervosa

OBJECTIVE

The purpose of the current study is to examine expressed emotion (EE) and long-term treatment outcome among adolescents participating in a randomized controlled trial (RCT) for treatment of anorexia nervosa (AN). It was hypothesized that patients with high EE parents at baseline would show more severe symptoms at end-of-treatment, 12-month follow-up, and 4-year follow-up than patients from low EE families.

METHOD

Secondary data analysis was conducted of original RCT data from a two-site eating disorder treatment trial conducted in the United States. Participants were 121 adolescents with AN who completed measures of EE, eating disorder psychopathology, depression, and self-esteem.

RESULTS

Generalized estimating equations showed that participants who were in the Low EE group achieved a more accelerated drop in depression scores in the context of treatment (first 12 months) than participants in the High EE group. No other significant Group × Time interactions were found.

DISCUSSION

Findings suggest that high parental EE at baseline does not indicate that adolescent patients with AN will fare poorly 4 years later.

The relationship between expressed emotion, personality traits and prognosis of alcohol and substance addiction: 6-month follow-up study

AIM

Preventing relapses in addiction and related factors are still being investigated. There is inadequate data, specifically, on the effects of expressed emotion (EE) among key relatives of patients with alcohol and substance use disorder (ASUD), the personality traits of patients, and the clinical features of addiction on relapses.

MATERIAL AND METHOD

This study was conducted with patients with ASUD (n = 102, 98 male) and their relatives (n = 102, 44 male). The Dependency Profile Index, and the Temperament and Character Inventory were applied to the patients, while the EE scale was applied to key relatives. Relapse rates were evaluated six months later.

RESULTS

EE levels among key relatives of patients were found to be associated with early relapse rates (p = 0.002). In addition, the individuals the patients lived with (p = 0.041), income level (p = 0.048), working status (p = 0.039), time spent in profession (p = 0.007), and severity of addiction (p = 0.016) were all found to be significantly associated with relapses. The personality traits of patients were not related to early relapses. In logistic regression analysis, EE and time spent in a profession were found to be significantly associated with relapses (p = 0.014, 0.043 respectively), while other variables were not significant.

CONCLUSION

The relationship between relapse in the early period of abstaining from substance use and EE levels of key relatives seems to be a greater determinant for ongoing success than several other variables in patients with ASUD, including addiction severity. The research suggests that families be involved in programs that help prevent relapses.

Paternal expressed emotion influences psychobiological indicators of threat and safety learning in daughters: A preliminary study

This preliminary study examined the association of children's anxiety, paternal expressed emotion (EE), and their interaction with psychophysiological indices of children's threat and safety learning. Participants included 24 father-daughter dyads. Daughters (ages 8-13 years, 100% Latina) self-reported their anxiety levels and completed a differential threat conditioning and extinction paradigm, during which psychophysiological responding was collected. Fathers completed a Five-Minute Speech Sample, from which paternal EE (i.e., criticism, emotional overinvolvement) was assessed. Anxiety-dependent associations emerged between paternal EE and individual differences in daughters' psychophysiological responding to safety signals during threat conditioning. Paternal EE was positively associated with psychophysiological responding to safety in daughters with high and mean, but not low, levels of anxiety. Although previous work suggests that chronic harsh maternal parenting is a potential risk factor for children's general threat and safety learning, these preliminary findings implicate milder forms of negative parenting behavior in fathers, particularly for highly anxious children.

Cultural research deconstructs the psychosocial construct 'expressed emotion'

Expressed emotion (EE) is a highly researched psychosocial construct. Cultural research challenges the assumption that high family criticism is a universal determinant of poor outcome, especially for chronic illness. The concept of warmth, an original component of EE, was dropped owing to the complexity of its measurement. Warmth has now been resurrected as an important predictor of good patient outcome. Cultural scrutiny and appropriate adaptation of any psychosocial construct is necessary before its acceptance into the medical lexicon of healthcare.

"Stuck between a Rock and a Hard Place": How Mental Health Nurses' Experience Psychosocial interventions in Irish Mental Health Care Settings

WHAT IS KNOWN ON THE SUBJECT?: Psychosocial interventions (PSI) are recognized and recommended internationally as they primarily focus on improving a client's mental health and preventing relapse. Limited qualitative studies focus on the similarities and differences on offering PSI in practice across many countries. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This manuscript provides readers with qualitative findings of mental health nurses' (MHNs) experiences of using PSI in practice and the need for regular clinical supervision to increase MHNs confidence and enhance the offering of PSI. MHNs want PSI guidelines for the offering of these skills to their client groups across practice settings. MHNs require work release from practice to attend supplementary training on PSI so that they can do their job adequately. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This study sheds light on the similarities and differences on PSI in Irish mental health services. It also highlights what MHNs recognize as important for PSI to be implemented. Clinical supervision and the development of PSI guidelines are necessary so that MHNs feel confident delivering these skills. They also need ongoing work release from practice to attend supplementary PSI training to provide best evidence to enhancing client experiences and positive PSI recovery outcomes. ABSTRACT: Description The paper will report on the interview data of trained MHNs' experiences of using PSI within the Irish context. This observational data will be reported elsewhere (Smyth et al. 2020-under review). Introduction This research is conducted when the current reform of Irish mental health governance demands clarification of key psychosocial skills (PSI) required for mental health nurses (MHNs) to embrace recovery-orientated ways of working. There is limited evidence about this important topic in Ireland and across countries. Aim To explore PSI-trained MHNs' experiences of using PSI within Ireland. Method A multiple case study methodology was used and situated within an interpretive paradigm. Data were gathered using semi-structured interviews with 40 PSI-trained MHNs. Findings Three overarching themes developed from the analysis. These included (a) PSI-trained MHNs' understanding and use of PSI; (b) facilitating factors supporting the use of PSI by PSI-trained MHNs; and (c) obstacles limiting the use of PSI by PSI-trained MHNs. Discussion MHNs recognize that regular clinical supervision is required to increase their confidence, along with PSI guidelines for the offering of these skills across practice settings. MHNs also need work release to attend supplementary training on PSI so that they can do their job adequately. Implications for practice This study suggests that MHNs are often stuck between a rock and a hard place when delivering PSI in practice. MHNs need to be aware that this can affect client outcomes. Relevance statement This research identified a gap in knowledge within the Irish context but also across the world on this important topic. MHNs need access to regular clinical supervision, PSI guidelines and ongoing PSI training to feel confident in order to keep abreast of the changes happening in mental health practice and research.

Involvement of informal carers in discharge planning and transition between hospital and community mental health care: A systematic review

WHAT IS KNOWN ON THE SUBJECT

Family members and friends (informal carers) are very important for providing support to people with mental health difficulties. When these carers are included to care planning patients seem to benefit, as they are less likely to relapse.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

There are three types of interventions including carers in the patients'transition 1) programmes that offer education in hospital; 2) programmes that involve carers in planning the patients discharge; and 3) programmes that involve carers in hospital care, discharge planning and also follow-up in the community. Interventions including carers that take place both in the hospital and the community have the clearest evidence for benefit on relapse reduction.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

Comprehensive interventions have the best evidence for effectiveness but challenges in their implementation and resourcing should be considered. It might worth trying to identify and test simpler interventions focusing on discharge planning that can be used in busy services and require more limited resources whilst providing opportunities for the participation of carers.

ABSTRACT

INTRODUCTION: Involving informal carers (family and friends of patients) in mental health interventions can lead to positive clinical and psychosocial outcomes such as relapse prevention or treatment adherence.

AIM/QUESTION

To explore the evidence on the effectiveness of different models that involve carers in the transition between hospital and community mental health care.

METHODS

Five electronic databases (PsycINFO, CINAHL, MEDLINE, Embase and Scopus) and Grey literature (Open Grey and Grey Literature report) were systematically searched. The results were analysed using a narrative synthesis.

RESULTS

Fourteen papers were identified. They described twelve interventions that were categorized into three groups: 1) purely educational programmes in preparation of discharge; 2) programmes that involved carers in planning the transition from the mental health inpatient treatment to community mental health services; and 3) programmes that bridged into the aftercare involving carers in community follow-up. The most comprehensive interventions, i.e. those including psychoeducation, care planning and aftercare follow-up were better evaluated and showed a clearer benefit in improving long-term outcomes and, in particular, reduce re-hospitalization.

IMPLICATIONS FOR PRACTICE

Comprehensive interventions showed the clearest benefit in improving long-term clinical outcomes of patients. Future research should explore implementation, costs and cost-effectiveness, as comprehensive interventions delivered across different settings are likely to require wide-ranging organizational changes and significant resources.

Family environmental factors in at-risk mental states for psychosis

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

Family involvement and patient-experienced improvement and satisfaction with care: a nationwide cross-sectional study in Danish psychiatric hospitals

BACKGROUND

Randomised controlled trials suggest that family therapy has a positive effect on the course of depression, schizophrenia and anorexia nervosa. However, it is largely unknown whether a positive link also exists between caregiver involvement and patient outcome in everyday psychiatric hospital care, using information reported directly from patients, i.e. patient-reported experience measures (PREM), and their caregivers. The objective of this study is to examine whether caregiver-reported involvement is associated with PREM regarding patient improvement and overall satisfaction with care.

METHODS

Using data from the National Survey of Psychiatric Patient Experiences 2018, we conducted a nationwide cross-sectional study in Danish psychiatric hospitals including patients and their caregivers who had been in contact with the hospital (n = 940 patients, n = 1008 caregivers). A unique patient identifier on the two distinct questionnaires for the patient and their caregiver enabled unambiguous linkage of data. In relation to PREM, five aspects of caregiver involvement were analysed using logistic regression with adjustment for patient age, sex and diagnosis.

RESULTS

We consistently find that high caregiver-reported involvement is statistically significantly associated with high patient-reported improvement and overall satisfaction with care with odds ratios (OR) ranging from 1.69 (95% confidence interval (CI) 0.95-2.99) to 4.09 (95% CI 2.48-6.76). This applies to the following aspects of caregiver-reported involvement: support for the patient-caregiver relationship, caregiver information, consideration for caregiver experiences and the involvement of caregivers in decision making. No statistically significant association is observed regarding whether caregivers talk to the staff about their expectations for the hospital contact.

CONCLUSION

This nationwide study implies that caregiver involvement focusing on the patient-caregiver relationship is positively associated with patient improvement and overall satisfaction with care in everyday psychiatric hospital care.

The impact of family environment on self-esteem and symptoms in early psychosis

Expressed emotion (EE) and self-esteem (SE) have been implicated in the onset and development of paranoia and positive symptoms of psychosis. However, the impact of EE on patients’ SE and ultimately on symptoms in the early stages of psychosis is still not fully understood. The main objectives of this study were to examine whether: (1) patients’ SE mediated the effect of relatives’ EE on patients’ positive symptoms and paranoia; (2) patients’ perceived EE mediated the effect of relatives’ EE on patients’ SE; (3) patients’ SE mediated between patients’ perceived EE and patients’ symptomatology; and (4) patients’ perceived EE and patients’ SE serially mediated the effect of relatives’ EE on patients’ positive symptoms and paranoia. Incipient psychosis patients (at-risk mental states and first-episode of psychosis) and their respective relatives completed measures of EE, SE, and symptoms. Findings indicated that: (1) patients’ perceived EE mediated the link between relatives’ EE and patients’ negative, but not positive, SE; (2) patients’ negative SE mediated the effect of patients’ perceived EE on positive symptoms and paranoia; (3) the association of relatives’ EE with positive symptoms and paranoia was serially mediated by an increased level of patients’ perceived EE leading to increases in negative SE; (4) high levels of patients’ distress moderated the effect of relatives’ EE on symptoms through patients’ perceived EE and negative SE. Findings emphasize that patients’ SE is relevant for understanding how microsocial environmental factors impact formation and expression of positive symptoms and paranoia in early psychosis. They suggest that broader interventions for patients and their relatives aiming at improving family dynamics might also improve patients’ negative SE and symptoms.

Using machine learning analyses of speech to classify levels of expressed emotion in parents of youth with mood disorders

Expressed emotion (EE), a measure of attitudes among caregivers towards a patient with a psychiatric disorder, is a robust predictor of relapse across mood and psychotic disorders. Because the measurement of EE is time-intensive and costly, its use in clinical settings has been limited. In an effort to automate EE classification, we evaluated whether machine learning (ML) applied to lexical features of speech samples can accurately categorize parents as high or low in EE and in its subtypes (criticism, overinvolvement, and warmth). The sample was 123 parents of youth who had active mood symptoms and a family history of bipolar disorder. Using ML algorithms, we achieved 75.2-81.8% accuracy (sensitivities of ~0.7 and specificities of ~0.8) in classifying parents as high or low in EE and EE subtypes. Additionally, machine-derived EE classifications and observer-rated EE classifications had simiar relationships with youth mood symptoms, parental distress, and family conflict. Of note, criticism related to greater manic severity, parental distress, and family conflict. Study findings indicate that EE classification can be automated through lexical analysis and suggest potential for facilitating larger-scale applications in clinical settings. The results also provide initial indications of the digital phenotypes that underlie EE and its subtypes.

All in the Family: How Parental Criticism Impacts Depressive Symptoms in Youth

Despite a strong connection between family environment and mood symptoms in youth, little research to date has examined potential underlying mechanisms. We propose an etiological model investigating how parenting (i.e., expressed emotion, or EE) affects youth depression by shaping their emotion regulation abilities. Forty-six youth and caregivers participated in this cross-sectional study. Family environment was assessed using the Five-Minute Speech Sample (FMSS) and the Levels of Expressed Emotion Scale (LEE). The Difficulties in Emotion Regulation Scale (DERS) and the Children's Depression Rating Scale-Revised (CDRS-R) were used to assess youth emotion regulation and depressive symptoms, respectively. Analyses demonstrated no significant relationships between type of reporter (i.e., independent rater, parent, youth) of parental EE and criticism. Mediation analyses suggested that youth-reported parental EE predicted greater levels of youth depressive symptoms, and that this association was mediated by emotion regulation. This study has direct clinical implications, elucidating the importance of strengthening positive parent-child communication to support the development of emotion regulation skills and psychological well-being for youth.

Interpersonal Relations Within the Context of Resource Groups for People With Severe Mental Illness: A Narrative Approach

Objective: The resource group method intends to promote patients' agency and self-management and to organize meaningful partnerships between patients and their informal and formal support systems. The aim of this study was to enhance the understanding of interpersonal dynamics that arise within resource groups for people with severe mental illness. Insight into these unfolding processes would enable improved implementation of the resource group method so that it contributes to establishing a positive social environment, which can lead to more enduring recovery. Methodology: We performed a narrative analysis of transcripts and field notes obtained in a longitudinal, qualitative study on the resource group method. The stories of four different resource groups were reconstructed and analyzed in depth. Data included a total of 36 interviews (with patients, significant others, and mental health professionals) and 18 observations of resource group meetings. Results: The degree to which the resource group method actually contributes to recovery was based on the extent to which the existing roles of and patterns between the patient and his/her resource group members were altered. Breaking through old patterns of inequality and the joint search for a new balance in relationships proved to be crucial processes for establishing an empowering resource group. The four cases showed that it takes time, patience, and small steps back and forth to overcome the struggles and fears related to finding new ways of relating to each other. An honest and reflective atmosphere in which all participants are encouraged to participate and be curious about themselves and each other is essential for changes in interpersonal dynamics to emerge. Such changes pave the way for individuals with SMI to find their own voices and pursue their unique recovery journeys. Conclusions: The functioning of the resource group and the ability of the involved members to respond in new ways are important when working toward the patient's recovery goals. The resource group method should therefore not be considered an intervention to organize informal support for the patient, but a platform to expose and adjust the functioning of the patient's social network as a whole.

The predictive power of expressed emotion and its components in relapse of schizophrenia: a meta-analysis and meta-regression

BACKGROUND

Schizophrenia is a longstanding condition and most patients experience multiple relapse in the course of the condition. High expressed emotion (HEE) has been found to be a predictor of relapse. This meta-analysis and meta-regression examined the association of global EE and relapse specifically focusing on timing of relapse and EE domains.

METHODS

Random-effects model was used to pool the effect estimates. Multiple random-effects meta-regression was used to compute the moderator analysis. Putative effect moderators including culture, EE measurements, age, length of condition and study quality were included.

RESULTS

Thirty-three prospective cohort studies comprising 2284 patients were included in the descriptive review and 30 studies were included for meta-analysis and meta-regression. Findings revealed that global HEE significantly predicted more on early relapse (⩽12 months) [OR 4.87 (95% CI 3.22-7.36)] than that on late relapse (>12 months) [OR 2.13 (95% CI 1.36-3.35)]. Higher level of critical comments (CC) significantly predicted relapse [OR 2.22 (95% CI 1.16-4.26)], whereas higher level of warmth significantly protected patients from relapse [OR 0.35 (95% CI 0.15-0.85)]. None of the moderators included significantly change the results.

CONCLUSIONS

These findings indicate that there is a dynamic interaction between EE-relapse association with time, and CC and warmth are the two important EE domains to influence relapse among patients with schizophrenia. Results also confirmed the foci of family interventions on reducing CC and improving warmth in relationship.

Incorporating family factors into treatment planning for adolescent depression: Perceived parental criticism predicts longitudinal symptom trajectory in the Youth Partners in Care trial

BACKGROUND

This study aimed to clarify the predictive significance of youth perceptions of parental criticism assessed using a brief measure designed to enhance clinical utility. We hypothesized that high perceived parental criticism would be associated with more severe depression over 18-months of follow-up.

METHODS

The study involved secondary analyses from the Youth Partners in Care trial, which demonstrated that a quality improvement intervention aimed at increasing access to evidence-based depression treatment in primary care led to improved depression outcomes at post-treatment compared to usual care enhanced by provider education regarding depression evaluation/management. Patients (N = 418; ages 13-21) were assessed at four time points: baseline; post-treatment (six-month follow-up); 12- and 18-month follow-ups. The primary analysis estimated the effect of perceived parental criticism on likelihood of severe depression (i.e., Center for Epidemiological Studies-Depression Scale ≥ 24) over post-intervention follow-ups using a repeated-measures logistic regression model. Secondarily, a linear mixed-effects growth model examined symptom trajectories from baseline through 18-months using the Mental Health Index-5, a measure of emotional distress available at all time-points.

RESULTS

High perceived parental criticism emerged as a robust predictor of clinically-elevated depression (OR=1.66, p=.02) and a more pernicious symptom trajectory over 18-months (β =-1.89, p<.0001).

LIMITATIONS

The association between the self-report perceived criticism and traditional expressed emotion measures derived from verbal and nonverbal parental behaviors was not evaluated.

CONCLUSIONS

Results support perceived parental criticism as a predictor of youth depression outcomes over 18-months. This brief measure can be feasibly integrated within clinical assessment to assist clinicians in optimizing treatment benefits.

Polygenic Risk for Major Depression Interacts with Parental Criticism in Predicting Adolescent Depressive Symptom Development

Research has focused more and more on the interplay between genetics and environment in predicting different forms of psychopathology, including depressive symptoms. While the polygenic nature of depressive symptoms is increasingly recognized, only few studies have applied a polygenic approach in gene-by-environment interaction (G × E) studies. Furthermore, longitudinal G × E studies on developmental psychopathological properties of depression are scarce. Therefore, this 6-year longitudinal community study examined the interaction between genetic risk for major depression and a multi-informant longitudinal index of critical parenting in relation to depressive symptom development from early to late adolescence. The sample consisted of 327 Dutch adolescents of European descent (56% boys; M_age T₁ = 13.00, SD_age T₁ = 0.44). Polygenic risk for major depression was based on the Hyde et al. (Nature Genetics, 48, 1031–1036, 2016) meta-analysis and genetic sensitivity analyses were based on the 23andMe discovery dataset. Latent Growth Models suggested that polygenic risk score for major depression was associated with higher depressive symptoms across adolescence (significant main effect), particularly for those experiencing elevated levels of critical parenting (significant G × E). These findings highlight how polygenic risk for major depression in combination with a general environmental factor impacts depressive symptom development from early to late adolescence.