A cross-cultural study on expressed emotion in carers of people with dementia and schizophrenia: Japan and England

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.

Risk and Resiliency Factors Related to Dementia Caregiver Mental Health

Prevalence rates for dementia are expected to rise exponentially as the elderly population rises. With this comes a corresponding increase in the number of family members who will become dementia caregivers. Caregivers of people with dementia often experience a deterioration in mental health. Identifying factors that relate to caregiver mental health is necessary to develop appropriate interventions. The current study explored how family functioning (measured with a latent variable that includes family cohesion, family balance, and family communication), caregiver expressed emotion (EE), and patient symptom severity related to caregiver mental health (measured with a latent variable that includes depression, anxiety, and stress). Participants included 107 dementia caregivers. The following specific hypotheses were tested: lower levels of both (1) EE and (2) patient symptom severity, and (3) higher levels of family functioning would be related to better caregiver mental health. Results produced a well-fitting model: X² (18) = 14.858, p = .672; CFI = 1.00; RMSEA = .00; SRMR = .037. Moreover, results indicated that better family functioning (Ɣ = -3.54, SE = 1.34, p = .008), lower levels of caregiver EE (β = .36, SE = 0.07, p < .01), and higher patient symptom severity (β = -3.03, SE = 0.88, p = .001) were related to better caregiver mental health. Results from this study suggest that efforts to bolster family functioning (i.e., enhance communication, promote cohesion, encourage flexibility) could help improve caregiver mental health.

Caregiver expressed emotion as mediator of the relationship between neuropsychiatric symptoms of dementia patients and caregiver mental health in Hong Kong

Objectives: Quality of life among Hong Kong's family dementia caregivers is a current heightened public health concern. This was one of the first East Asian studies to examine the role of family expressed emotion (EE) in the negative caregiver outcomes associated with dementia caregiving. EE comprises overinvolved and critical communications in families of people with mental illness. In this research, caregiver EE was evaluated as a mediator of the relationship between behavioral and psychological problems associated with dementia (BPSD) and negative caregiver outcomes.Method: Participants were 89 Hong Kong family caregivers (79% female, 84% married, 43% >50 years of age) of people with diagnosed dementia, recruited from elder day care centers. Caregivers completed the Neuropsychiatric Inventory (NPI), Cohen Mansfield Agitation Inventory (CMAI), Level of Expressed Emotion scale (LEE), Zarit Burden Interview, and Center for Epidemiological Studies Depression Scale (CES-D).Results: Agitation, delusions, hallucinations, aggression and irritability were BPSD most associated with caregiver burden and depression. EE significantly mediated the BPSD-negative caregiver outcome relationship. Among EE subscales, intrusiveness was significantly more common and less associated with negative caregiver outcomes. Caregiving hours, low family support, and religious nonaffiliation were associated with EE and poorer caregiver outcomes.Conclusions: The negative impact of BPSD on dementia caregivers in Hong Kong is influenced by EE. Higher scores on EE intrusiveness may be partly accounted for by filial piety, a strong sense of family responsibility characterized by high attentiveness to elderly family members. As EE is a potentially modifiable factor, interventions are considered.

Affective temperament traits may explain high expressed emotion in caregivers of patients with Alzheimer's disease

BACKGROUND

The negative interactions between Alzheimer's disease (AD) patients and their caregivers may provoke criticism, hostility, and emotional overinvolvement that characterise highly expressed emotion (EE) attitudes. In this study, we hypothesised that affective temperament traits of AD caregivers are related to their high EE levels independent from other patient and caregiver characteristics.

METHODS

Eighty AD patients were assessed through Clinical Dementia Rating Scale (CDR), and Mini-Mental State Examination. Expressed Emotion Scale (EES), Temperament Evaluation of Memphis, Pisa, Paris and San Diego auto-questionnaire, and Hamilton Depression Rating Scale were applied to the caregivers. The high (n = 41) and low EE caregivers (n = 39) were compared with respect to some sociodemographic and clinical characteristics of the patients and caregivers, and affective temperament traits of caregivers. The associations of caregiver EES scores with multiple variables related to patients and caregivers were examined by Pearson correlation tests. We performed multiple linear regression analysis to determine the possible predictors of total EES scores.

RESULTS

High EE caregivers had significantly higher depressive, cyclothymic, and anxious temperament traits than in low EE subjects. A weak positive correlation was found between the total EES scores and Personal Care scores of CDR. Home and hobbies subscale scores of CDR had a moderately significant positive correlation with total EES scores. There was also moderate significant positive correlations between total EE scores and depressive, cyclothymic, anxious, and irritable temperament traits. Linear regression analysis indicated that depressive temperament significantly predicted the high levels of caregiver EE.

CONCLUSION

These findings suggest that caregivers' depressive temperament is predominantly related to their EE levels even after controlling for the severity of AD, and lower educational level of caregivers. Our results may provide evidence that high EE might be a reflection of caregivers' depressive temperament traits, in accordance with the trait hypothesis.

The effect of psychosocial support on caregivers' perceived criticism and emotional over-involvement of persons with dementia: an assessor-blinded randomized controlled trial

BACKGROUND

Many relatives of close family members suffering from dementia have taken on the caregiver role. While intervention studies have revealed promising results on caregiver burden, distress, and depression, there is a lack of knowledge about how caregivers' perceived relationship with their ill family member influences the burden of care. This study examined whether a psychosocial intervention influenced this perceived relationship from the caregivers' perspective. We also explored whether the caregivers' perception of the care receiver's attitude and behavior changed over time, and whether caregiver stress and mood differed following the intervention.

METHODS

The participating caregivers and care receivers were randomly assigned to a psychosocial intervention comprising education about dementia, counselling and group sessions, or to treatment as usual. The study investigated caregivers' experience of expressed emotion using the Felt Expressed Emotion Rating Scale (FEERS), a self-report questionnaire that captures caregivers' perception of criticism (CC) and emotional over-involvement (EOI) exhibited by the family members with dementia.

RESULTS

A total of 208 dyads were enrolled in the study. There were no significant differences between the intervention and control groups in the studied variables. Caregivers' perception of CC and EOI was low but fluctuated somewhat, whereas their mood and stress level were stable during the follow-up period.

CONCLUSIONS

According to the FEERS, the intervention did not influence caregivers' perception of CC and EOI, and there was no difference between the intervention and control groups regarding caregivers' perceived relationship. Despite the increased symptoms of dementia, caregivers' level of distress and mood remained stable, and they seemed to maintain a positive perception of the quality of their relationship with the care receiver.

TRIAL REGISTRATION

Clinical.Trials.gov Sept. 2009, NCT01287767.

Stigma, Expressed Emotion, and Quality of Life in Caregivers of Individuals with Dementia

Expressed emotion (EE) is a measure of a caregiver's critical and emotionally overinvolved (EOI; e.g., intrusive, self-sacrificing) attitudes and behaviors toward a person with a mental illness. Mounting evidence indicates that high levels of these critical and EOI attitudes and behaviors (collectively termed high EE) in family members are associated with a poorer course of illness for people with a range of disorders, including dementia (Nomura et al., 2005). However, less is known about factors that might trigger high EE and how high EE might impact dementia caregivers' own mental health. In this study we propose that caregivers who perceive stigma from their relative's illness may be more likely to be critical or intrusive (high EOI) toward their relative in an attempt to control symptomatic behaviors. We further hypothesized that high EE would partially mediate the link between stigma and quality of life (QoL) as there is some evidence that high EE is associated with poorer mental health in caregivers themselves (Safavi et al., 2015). In line with study hypotheses and using a sample of 106 dementia caregivers, we found that greater caregiver stigma was associated with both high EE (for criticism and EOI) and with poorer QoL. Mediational analyses further confirmed that high EE accounts for much of the association between stigma and poorer QoL. Study results suggest that addressing caregiver stigma in therapy could reduce levels of high EE and indirectly therefore improve caregiver QoL. Intervening directly to reduce high EE could also improve caregiver QoL.

Spared emotional perception in patients with Alzheimer's disease is associated with negative caregiver outcomes

OBJECTIVES

Caregivers (CGs) for patients with Alzheimer's disease (AD) often experience negative mental health and relationship outcomes. Additionally, emotional perception abilities are often compromised in early AD; the relationships between these deficits and CG outcomes are unclear. The present study investigated the relationship between emotional perception abilities in AD participants and CG well-being.

METHODS

Participants included 28 individuals with AD, their spousal CGs, and 30 older controls (OCs). Patients and controls completed the Montreal Cognitive Assessment and Advanced Clinical Solutions: Social Perception subtest. CGs completed questionnaires related to relationship satisfaction, burden, depression, and patient neuropsychiatric symptoms and activities of daily living.

RESULTS

The patient group performed significantly worse than OCs on measures of cognition and emotional perception. Several significant relationships emerged between AD participant emotional perception and CG outcomes. Higher CG depression was associated with greater overall emotional perception abilities (r = .39, p = .041). Caregiver burden was positively correlated with AD participants' ability to label the emotional tones of voices (r = .47, p = .015). Relationship satisfaction was not significantly correlated with emotional perception.

DISCUSSION

This study replicated earlier findings of impaired emotional perception abilities in AD participants. However, preserved abilities in emotional perception were associated greater CG depression and burden. Interestingly, the CGs satisfaction with the marital relationship did not appear to be influenced by changes in emotional perception. Higher emotional engagement among couples in which one spouse has cognitive impairment may contribute to increased negative interactions and in turn a greater sense of burden and depression, while leaving the marital relationship preserved.

Expressed emotion and the course of schizophrenia in Pakistan

PURPOSE

Aim of the study is to evaluate the predictive power of Expressed Emotion in Schizophrenia relapse in Pakistan.

METHOD

A longitudinal study was conducted comprising 53 in-patients' sample diagnosed with Schizophrenia and their 101 key carers. Participants fulfilled DSM-IV-TR criteria for Schizophrenia based on Structural Clinical Interview for the DSM-IV diagnosis. Symptomatic status was measured through Brief Psychiatric Rating Scales-Expanded (BPRS-E). Caregivers' level of EE was assessed through Camberwell Family Interview (CFI). Patients were followed up for 9 months after hospital discharge.

RESULTS

Relapse rate for patients with high-EE household was 72% as compared with 36% in the low-EE household. Logistic Regression showed a positive relationship between high-EE and relapse (CI 0.06-0.80; p < 0.05). Both hostility and critical comments emerged as significant predictors of relapse. The odds ratio showed that a one unit increase in caregivers' score on the CCs and hostility scales were associated with a 1.29 (CI 1.06-1.56; p < 0.05) and 1.89 (CI 1.14-3.13; p < 0.05) times increased rate of relapse, respectively. Conversely, a non-significant relationship was observed between EOI and relapse.

CONCLUSIONS

The findings from this study confirmed the validity of EE construct in predicting schizophrenia relapse in a Pakistani sample. However, medication compliance has not been experimentally controlled and that is one of the limitations of the study.

Relationship Quality and Distress in Caregivers of Persons With Dementia: A Cross-Sectional Study

This cross-sectional study aimed to investigate the relationship between caregivers and care receivers, defined as home-dwelling family members with dementia. We used a self-rating questionnaire, the Felt Expressed Emotion Rating Scale (FEERS; 6 simple questions), to measure caregiver perceptions of the care receiver's criticisms (CCs) and emotional overinvolvement (EOI) toward the caregiver. We performed factor analyses to rank single items on the FEERS pertaining to CC and EOI. We included 208 caregiver/care receiver pairs. Logistic regression analyses tested associations between FEERS items and caregiver and care receiver variables. The main contributors to caregiver perceptions of CC were the caregiver's own distress and the amount of time spent with the care receiver. Socially distressed caregivers perceived the care receiver as emotionally overinvolved. When offering a psychosocial intervention, a tailored program should target the caregiver's perceived relationship with the family member and the caregiver's distress. The program should also endeavor to give the caretaker more opportunities for leisure time.

Expressed Emotion in relatives of persons with dementia: a systematic review and meta-analysis

OBJECTIVES

Expressed Emotion (EE) refers to a number of key aspects of interpersonal relationships which have been shown to relate to outcomes in relatives of people with health conditions.

DESIGN

A systematic review and meta-analysis of EE and outcomes in relatives of persons with dementia is reported. Potential research studies were identified via a search of three electronic databases; PsychINFO, MEDLINE and the Web of Science between 1960 and 2015.

RESULTS

We reviewed 12 studies investigating correlations between EE and well-being in relatives of patients with dementia. Factors hypothesised to influence EE including attributions, social support, coping strategies and relationship quality were also reviewed.

CONCLUSION

High-EE relatives were found to have increased levels of burden (Z = 6.967, P < 0.001) and greater levels of depression (Z = 5.842, P < 0.001). Compared to low-EE relatives, high-EE relatives were more likely to attribute the patient's problems to factors that were personal to and controllable by the patient. Relatives with less social support, inefficient coping strategies and a poor relationship with the patients, were more likely to be classified as high-EE.

Expressed emotion and depression in caregivers of older adults with dementia: results from Taiwan

OBJECTIVES

The purpose of this study was to examine the relationship between (1) expressed emotion (EE) and characteristics of Taiwanese dementia patients and their family caregivers and (2) EE and depressed mood, burden, and perception of health in Taiwanese caregivers of elderly persons with dementia.

METHODS

Sixty-five primary caregivers of elderly persons with mild to severe dementia were recruited from institutions in Taiwan and they completed four standardized questionnaires: Level of Expressed Emotion (LEE) scale, Center for Epidemiologic Studies Depression (CES-D) scale, Zarit Burden Inventory (ZBI), and General Health Perceptions subscale of the Medical Outcomes Study Short Form 36 Health Survey (MOS SF-36).

RESULTS

EE was positively associated with caregiver depression (r = .543; p < .001) and burden (r = .532; p < .001), and negatively associated with caregivers' perceived health (r = -.316; p = .010). The higher the caregivers' depression and burden, the greater was their EE and the lower the caregivers' perceived health, the higher was their EE. EE was negatively associated with caregiver education (r = -.279; p = .024) and income (r = -.261; p = .036). The lower the caregivers' education and income, the higher was their EE.

CONCLUSION

The significant relationship between EE and caregivers' mood and perceived burden suggests that caregivers with elevated mood or burden may put persons with dementia at greater risk for toxic, negative interactions from them. Although this study's design precludes attributing directionality, more depressed caregivers are at a greater risk of higher EE which may affect care of their elderly demented family members. Additional research is warranted with a larger sample size and/or a longitudinal design.

Evaluation of psychometric properties of the Chinese Mandarin version State-Trait Anxiety Inventory Y form in Taiwanese outpatients with anxiety disorders

This study was conducted to develop the Chinese Mandarin State-Trait Anxiety Inventory Y form and to evaluate its psychometric properties among Taiwanese outpatients with anxiety disorders. A three-phase survey questionnaire was used to gather cross-sectional data. Non-hospitalized adults (n= 306) with anxiety disorders were recruited from mental health clinics in central Taiwan. Cronbach's alpha reliabilities for the state and trait anxiety subscales were 0.91 and 0.92, respectively. The 2-week test-retest reliabilities for the state and trait anxiety subscales were 0.76 and 0.91, respectively. Criterion validity of the scale was supported by its high correlations with the interview version of the Chinese Hamilton Anxiety Rating Scale (r= 0.69 for state and 0.74 for trait anxiety). Construct validity of the scale was confirmed by a four-factor structure, showing slightly adequate representation of the data. The scale was shown to be reliable and may be valid for measuring anxiety in Taiwanese adults with anxiety disorders.

Cross-national differences in the prevalence and correlates of burden among older family caregivers in the World Health Organization World Mental Health (WMH) Surveys

BACKGROUND

Current trends in population aging affect both recipients and providers of informal family caregiving, as the pool of family caregivers is shrinking while demand is increasing. Epidemiological research has not yet examined the implications of these trends for burdens experienced by aging family caregivers. Method Cross-sectional community surveys in 20 countries asked 13 892 respondents aged 50+ years about the objective (time, financial) and subjective (distress, embarrassment) burdens they experience in providing care to first-degree relatives with 12 broadly defined serious physical and mental conditions. Differential burden was examined by country income category, kinship status and type of condition.

RESULTS

Among the 26.9-42.5% respondents in high-, upper-middle-, and low-/lower-middle-income countries reporting serious relative health conditions, 35.7-42.5% reported burden. Of those, 25.2-29.0% spent time and 13.5-19.4% money, while 24.4-30.6% felt distress and 6.4-21.7% embarrassment. Mean caregiving hours per week in those giving any time were 16.6-23.6 (169.9-205.8 h/week per 100 people aged 50+ years). Burden in low-/lower-middle-income countries was 2- to 3-fold higher than in higher-income countries, with any financial burden averaging 14.3% of median family income in high-, 17.7% in upper-middle-, and 39.8% in low-/lower-middle-income countries. Higher burden was reported by women than men and for conditions of spouses and children than parents or siblings.

CONCLUSIONS

Uncompensated family caregiving is an important societal asset that offsets rising formal healthcare costs. However, the substantial burdens experienced by aging caregivers across multiple family health conditions and geographic regions threaten the continued integrity of their caregiving capacity. Initiatives supporting older family caregivers are consequently needed, especially in low-/lower-middle-income countries.

The predictive validity of expressed emotions (EE) in schizophrenia. A 20-year prospective study

BACKGROUND

The level of expressed emotions in the family (EE) and components thereof (emotional over-involvement EOI, and critical comments CC) have been found to be related to treatment outcomes in psychotic patients. One point of interest is the dynamic of various outcomes in relation to initial EE, CC and EOI levels.

METHOD

43 individuals with diagnosis of schizophrenia were assessed at 1, 3, 7, 12 and 20-year follow-ups. The EE indicator was evaluated during the index hospitalization. Outcome indicators included: number of relapses, number and duration of in-patient rehospitalizations, and severity of psychopathological symptoms.

RESULTS

1) A high EE indicator was associated with a higher number of relapses in every follow-up and differences between the groups with low and high EE indicators proved significant after 3, 7, 12 and 20 years of the illness. 2) A high EE indicator was associated with a higher number of rehospitalizations after 3 and 7 years, and showed as a clear trend after 12 and 20 years. 3) A high level of CC was associated with a higher number of relapses. 4) The severity of positive symptoms increased only in the group with high CC. 5) The negative syndrome was not associated with EE, EOI or CC.

CONCLUSIONS

The EE indicator may be considered a valid prolonged predictor of relapses and rehospitalizations. A high level of CC was associated with a higher number of relapses and intensification of the positive syndrome in both the short-term and long-term course of the illness.

The association between expressed emotion, illness severity and subjective burden of care in relatives of patients with schizophrenia. Findings from an Italian population

BACKGROUND

An appropriate understanding of the association between high-Expressed Emotion (EE) in family members of people with schizophrenia, patients' and relatives' correlates is needed to improve adaptation of psychoeducational interventions in diverse cultures. The aim of this study was to test the hypothesis that relatives designated as high EE would report higher subjective burden of care, and would be associated with objective variables that indicate greater illness severity i.e. number of previous hospitalizations and duration of illness.

METHODS

We performed secondary analyses of baseline data from a randomized controlled trial conducted in Italy.

RESULTS

High-EE relatives reported more subjective burden of care in disturbed behaviours and adverse effects areas, but did not perceive more deficits in social role performances. As regards illness severity characteristics, neither the number of previous hospital admissions nor the duration of illness was associated with high-EE. However, patients' previous psychosocial functioning, as measured by educational attainments, seems to protect the relative from high-EE status.

CONCLUSION

There is a need for cross-cultural comparisons of the subjective experience of distress and burden among high EE carers as a target for intervention, aimed at reducing family stress as much as improving patient outcomes.

Comparative prevalence, correlates of impairment, and service utilization for eating disorders across US ethnic groups: Implications for reducing ethnic disparities in health care access for eating disorders

OBJECTIVE

The study compared the prevalence, correlates of functional impairment, and service utilization for eating disorders across Latinos, Asians, and African Americans living in the United States to non-Latino Whites.

METHOD

Pooled data from the NIMH Collaborative Psychiatric Epidemiological Studies (CPES;NIMH, 2007) were used.

RESULTS

The prevalence of anorexia nervosa (AN) and binge-eating disorder (BED) were similar across all groups examined, but bulimia nervosa (BN) was more prevalent among Latinos and African Americans than non-Latino Whites. Despite similar prevalence of BED among ethnic groups examined, lifetime prevalence of any binge eating (ABE) was greater among each of the ethnic minority groups in comparison to non-Latino Whites. Lifetime prevalence of mental health service utilization was lower among ethnic minority groups studied than for non-Latino Whites for respondents with a lifetime history of any eating disorder.

DISCUSSION

These findings suggest the need for clinician training and health policy interventions to achieve optimal and equitable care for eating disorders across all ethnic groups in the United States.

Caregiver burden and coping strategies for patients with schizophrenia: comparison between Japan and Korea

AIM

With the current shift to community-centered mental health services, considerable research on the family burden of caring for patients with schizophrenia has been conducted in developed countries. However, there has been no investigation of families with Japanese or Korean sociocultural backgrounds. Therefore, the present study compared the caregiver burden and coping strategies of families of patients with schizophrenia in Japan and Korea in order to elucidate similarities and differences in the sociocultural factors that affect the care experience of families in Northeast Asia.

METHODS

A total of 99 Japanese (Nagasaki) and 92 Korean (Seoul, Daegu) family members of patients with schizophrenia were surveyed in regards to caregiver burden, coping strategies, and nursing awareness of the caregiver role regarding the patient with schizophrenia.

RESULTS

Analysis revealed the following: (i) although no difference in caregiver burden and coping strategy was observed between the countries, the nursing awareness of families' caregiver role was significantly higher in Japan than in Korea; (ii) caregiver burden was significantly associated with the patient's social functioning and care needs in both countries; and (iii) caregiver burden was significantly associated with reduction of social interests, coercion, avoidance, resignation, and nursing awareness of caregiver role in both countries.

CONCLUSION

Although the nursing awareness of families' roles in caring for patients with schizophrenia differed between Japan and Korea, similar trends were observed for the causes of caregiver burden. These findings suggest that in order to provide effective support for reducing caregiver burden, the necessity of such support must be emphasized in both countries.

Family caregivers of people with dementia

Family caregivers of people with dementia, often called the invisible second patients, are critical to the quality of life of the care recipients. The effects of being a family caregiver, though sometimes positive, are generally negative, with high rates of burden and psychological morbidity as well as social isolation, physical ill-health, and financial hardship. Caregivers vulnerable to adverse effects can be identified, as can factors which ameliorate or exacerbate burden and strain. Psychosocial interventions have been demonstrated to reduce caregiver burden and depression and delay nursing home admission. Comprehensive management of the patient with dementia includes building a partnership between health professionals and family caregivers, referral to Alzheimer's Associations, and psychosocial interventions where indicated.

Family and patient predictors of symptomatic status in schizophrenia

OBJECTIVE

To test an interactive hypothesis that, in schizophrenia, a combination of patients' and relatives' characteristics at 1-month postdischarge from hospital (Time 1 [T1]) better predicts the level of psychotic symptoms at follow-up (Time 2 [T2]), than do the characteristics of patients or relatives alone.

METHODS

Male patients (n = 38) with a diagnosis of schizophrenia, without substance abuse, and in contact with their families, were recruited at the time of hospital discharge. Patients' psychotic symptom levels were monitored every 2 weeks until follow-up, while family measures were administered at T1 and T2. The 4 predictor variables in the regression analysis were T1 symptom levels of the patient and 3 measures of family interaction (expressed emotion, family burden, and family functioning).

RESULTS

The model based on the family variable, family burden at T1, and the patient variable, patients' remitted levels of psychotic symptoms at T1, was found to significantly predict the level of psychotic symptoms at T2. These 2 T1 variables made independent and additive contributions to the level of psychotic symptoms at T2, predicting 19% of the variance. Neither expressed emotion nor family functioning at T1 added to the prediction.

CONCLUSION

This finding suggests a patient-family interactional component to symptomatic relapse in schizophrenia.

Expressed emotion and relapse of psychopathology

Expressed emotion (EE) is a measure of the family environment that predicts worse clinical outcomes for patients with a range of disorders. This article describes the assessment of EE and the evidence linking EE to clinical relapse in patients with psychopathology. This is followed by consideration of the possible explanatory models that might account for the EE-relapse link and a review of the evidence suggesting that EE may play a causal role in the relapse process. The results of studies describing the effect of EE on patients, as well as cross-cultural aspects of the construct, are highlighted. Finally, the possibility that high levels of EE may stress patients by perturbing activity in neural circuits that underlie psychopathology is considered and new directions for EE research are outlined.

Stigma towards people with mental illness in developing countries in Asia

BACKGROUND

There is a wide range of literature on stigmatization and discrimination of people with mental illness. Most studies, however, derive from Western countries. This review aims at summarizing results from developing countries in Asia published between 1996-2006.

METHOD

Medline search focusing on English-speaking literature.

RESULTS

Comparable to Western countries, there is a widespread tendency to stigmatize and discriminate people with mental illness in Asia. People with mental illness are considered as dangerous and aggressive which in turn increases the social distance. The role of supernatural, religious and magical approaches to mental illness is prevailing. The pathway to care is often shaped by scepticism towards mental health services and the treatments offered. Stigma experienced from family members is pervasive. Moreover, social disapproval and devaluation of families with mentally ill individuals are an important concern. This holds true particularly with regards to marriage, marital separation and divorce. Psychic symptoms, unlike somatic symptoms, are construed as socially disadvantageous. Thus, somatisation of psychiatric disorders is widespread in Asia. The most urgent problem of mental health care in Asia is the lack of personal and financial resources. Thus, mental health professionals are mostly located in urban areas. This increases the barriers to seek help and contributes to the stigmatization of the mentally ill. The attitude of mental health professionals towards people with mental illness is often stigmatizing.

CONCLUSION

This review revealed that the stigmatization of people with mental illness is widespread in Asia. The features of stigmatization-beliefs about causes of and attitudes towards mental illness, consequences for help-seeking-have more commonalities than differences to Western countries.