Positive affect in the family environment protects against relapse in first-episode psychosis

User-Centered Development of Bolster, an mHealth Intervention for Early Psychosis Caregivers: Needs Assessment, Prototyping, and Field Trial

BACKGROUND

Caregivers play a critical role in the treatment and recovery of youth and young adults at risk for psychosis. Caregivers often report feeling isolated, overwhelmed, and lacking in resources. Mobile health (mHealth) has the potential to provide scalable, accessible, and in-the-moment support to caregivers. To date, few if any mHealth resources have been developed specifically for this population.

OBJECTIVE

The aim of this study was to conduct user-centered design and testing of an mHealth intervention to support early psychosis caregivers.

METHODS

We conducted a multiphase user-centered development process to develop the Bolster mobile app. In phase 1, a total of 21 caregivers were recruited to participate in a qualitative needs assessment and respond to an initial prototype of the Bolster platform. Content analysis was used to identify key needs and design objectives, which guided the development of the Bolster mobile app. In phase 2, a total of 11 caregivers were recruited to participate in a 1-week field trial wherein they provided qualitative and quantitative feedback regarding the usability and acceptability of Bolster; in addition, they provided baseline and posttest assessments of the measures of distress, illness appraisals, and family communication.

RESULTS

In phase 1, participants identified psychoeducation, communication coaching, a guide to seeking services, and support for coping as areas to address. Live prototype interaction sessions led to multiple design objectives, including ensuring that messages from the platform were actionable and tailored to the caregiver experience, delivering messages in multiple modalities (eg, video and text), and eliminating a messaging-style interface. These conclusions were used to develop the final version of Bolster tested in the field trial. In phase 2, of the 11 caregivers, 10 (91%) reported that they would use Bolster if they had access to it and would recommend it to another caregiver. They also reported marked changes in their appraisals of illness (Cohen d=0.55-0.68), distress (Cohen d=1.77), and expressed emotion (Cohen d=0.52).

CONCLUSIONS

To our knowledge, this study is the first to design an mHealth intervention specifically for early psychosis caregivers. Preliminary data suggest that Bolster is usable, acceptable, and promising to improve key targets and outcomes. A future fully powered clinical trial will help determine whether mHealth can reduce caregiver burdens and increase engagement in services among individuals affected by psychosis.

Being more satisfied with romantic relationship status is associated with increased mental wellbeing in people with experience of psychosis

Aims

Romantic relationships represent one of the most salient sources of social support. In general population studies, they are associated with both physical and psychological benefits. Research suggests that for people with psychosis, romantic relationships may also have a positive impact on a range of outcomes, but the reasons for these associations are still unclear. This study aims to investigate whether satisfaction with romantic relationships status is associated with better wellbeing outcomes in people with experience of psychosis and explore three possible psychological mediators of this relationship.

Methods

Participants who had previously sought support for psychosis (n = 190) completed an online survey including measures of relationship status satisfaction (the Satisfaction with Relationship Scale) as well as measures of psychotic symptoms (the CAPE-42), general well-being (Short Warwick-Edinburgh Mental Wellbeing Scale) and several psychological variables relevant to the pathway between romantic relationships and well-being outcomes, namely loneliness, internalised stigma, self-esteem and attachment.

Results

Fearful attachment and partner criticism were negatively associated with relationship status satisfaction. Having a partner was positively associated with relationship status satisfaction. Higher levels of relationship status satisfaction were associated with lower psychotic symptoms and higher mental wellbeing. This relationship was mediated by loneliness, internalised stigma, and self-esteem.

Conclusion

Mental health services should be mindful of the associations between romantic relationship satisfaction and wellbeing. Service users with a fearful attachment style may particularly benefit from support in this area.

Moderated Online Social Therapy for Carers of Early Psychosis Clients in Real-World Settings: Cluster Randomized Controlled Trial

BACKGROUND

Family carers of youth recovering from early psychosis experience significant stress; however, access to effective family interventions is poor. Digital interventions provide a promising solution.

OBJECTIVE

Our objective was to evaluate across multiple Australian early psychosis services the effectiveness of a novel, web-based early psychosis intervention for carers.

METHODS

In this cluster randomized controlled trial conducted across multiple Australian early psychosis services, our digital moderated online social therapy for carers (Altitudes) plus enhanced family treatment as usual (TAU) was compared with TAU alone on the primary outcome of perceived stress and secondary outcomes including mental health symptoms and family variables at the 6-month follow-up.

RESULTS

Eighty-six caregivers were randomized and data were available for 74 young people in their care. Our primary hypothesis that carers randomized to Altitudes+TAU would report greater improvements in perceived stress at follow-up compared with carers randomized to TAU alone was not supported, with the TAU alone group showing more improvement. For secondary outcomes, the TAU alone group showed improved mindfulness over time. Regardless of group assignment, we observed improvements in satisfaction with life, quality of life, emotional overinvolvement, and burden of care. In contrast, hair cortisol concentration increased. Post hoc analyses revealed more contact with early psychosis services in the intervention group compared to TAU alone and that improvements in perceived stress and social support were associated with use of the intervention in the Altitudes+TAU group. In this study, 80% (12/15) reported a positive experience with Altitudes and 93% (14/15) would recommend it to others.

CONCLUSIONS

Our trial did not show a treatment effect for Altitudes in perceived stress. However, our post hoc analysis indicated that the amount of use of Altitudes related to improvements in stress and social support. Additional design work is indicated to continue users' engagement and to significantly improve outcomes in problem-solving, communication, and self-care.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12617000942358; https://trialsearch.who.int/Trial2.aspx?TrialID=ACTRN12617000942358.

Tensor factorization approach for ERP-based assessment of schizotypy in a novel auditory oddball task on perceived family stress

Objective. Schizotypy, a potential phenotype for schizophrenia, is a personality trait that depicts psychosis-like signs in the normal range of psychosis continuum. Family communication may affect the social functioning of people with schizotypy. Greater family stress, such as irritability, criticism and less praise, is perceived at a higher level of schizotypy. This study aims to determine the differences between people with high and low levels of schizotypy using electroencephalography (EEG) during criticism, praise and neutral comments. EEGs were recorded from 29 participants in the general community who varied from low schizotypy to high schizotypy (HS) during a novel emotional auditory oddball task.Approach. We consider the difference in event-related potential parameters, namely the amplitude and latency of P300 subcomponents (P3a and P3b), between pairs of target words (standard, positive, negative and neutral). A model based on tensor factorization is then proposed to detect these components from the EEG using the CANDECOMP/PARAFAC decomposition technique. Finally, we employ the mutual information estimation method to select influential features for classification.Main results.The highest classification accuracy, sensitivity, and specificity of 93.1%, 94.73%, and 90% are obtained via leave-one-out cross validation.Significance. This is the first attempt to investigate the identification of individuals with psychometrically-defined HS from brain responses that are specifically associated with perceiving family stress and schizotypy. By measuring these brain responses to social stress, we achieve the goal of improving the accuracy in detection of early episodes of psychosis.

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.

Symptomatic and full remission rates in first-episode psychosis: A 12-month follow-up study in Korea

AIM

In the present study, the prevalence and predictors of symptomatic and full remission were investigated in patients with first-episode psychosis (FEP) at the 12-month follow-up.

METHODS

A total of 308 participants aged 18-45 years fulfilled the study inclusion criteria and 214 completed the 12-month follow-up.

RESULTS

At the 12-month follow-up, 67.3% (142) and 25.9% (55) of the FEP patients met the criteria for symptomatic and full remission, respectively. Stepwise logistic regression analysis showed a shorter duration of untreated psychosis (DUP), no family history, lower Positive and Negative Syndrome Scale (PANSS) negative symptom scores at baseline and higher familial support predicted symptomatic remission at the 12-month follow-up. A higher educational level, shorter DUP, lower PANSS general symptoms scores at baseline and higher subjective well-being under neuroleptics emotional regulation scores predicted full remission.

CONCLUSIONS

Our findings regarding the rates of symptomatic and full remission are consistent with previous studies. The results indicate a large discrepancy between symptomatic versus full remission rates at a 12-month follow-up in patients with FEP. Effective psychosocial interventions are necessary to improve the outcomes of FEP patients.

Association between Parents’ Relationship, Emotion-Regulation Strategies, and Psychotic-like Experiences in Adolescents

This study aimed to examine the association between the psychotic-like experiences (PLEs) and emotion-regulation (ER) strategies of adolescents and their parents’ relationship, and we hypothesized that the parents’ relationship moderates the link between ER strategies and PLEs. We recruited a total of 2708 first-year college students (1659 males and 1049 females) aged 15–20 years (mean = 17.9). Participants completed assessments of PLEs, their use of ER strategies, and reported their parents’ relationship as harmonious, conflicting, or divorced. Regression analyses indicated that the lower the use of the emotion-reappraisal strategy, the greater the use of the emotion-suppression strategy and that parental conflict or divorce predicted the number of PLEs endorsed and the level of distress from the PLEs. The parents’ relationship moderated the association between ER strategies and distress from PLEs. Among those who reported parental conflict or divorce, their lower use of the reappraisal strategy predicted their experiencing higher levels of distress from their PLEs. This study suggested the direct and interactive influence of the parents’ relationship and ER strategies on the presence of PLEs and PLE-related distress levels among adolescents, which may represent potential intervention targets.

Expressed Emotion and Attributions in Parents With Schizophrenia

We examined expressed emotion (EE) and attributions in parents with schizophrenia and compared them to parents without serious mental illness (SMI) in order to better understand the emotional climate of families in which a parent has schizophrenia. Parenting practices and parental reports of child behavior were also compared between the two groups. The relationship of EE to attributions was examined in each group separately. Relationships between parental mental health, EE, and attributions were explored in the parents with schizophrenia only. The Camberwell Family Interview was used to determine both EE and attributions in 20 parents with schizophrenia and 20 parents without SMI. We found that more parents with schizophrenia were rated as high EE than those without (60 and 35%, respectively) although this was not a statistically significant difference. Parents with schizophrenia demonstrated significantly more hostility and criticism toward their children than those without SMI and made more child-blaming attributions. Blame was associated with increased hostility, less warmth, and fewer positive remarks. Parental warmth was related to greater parenting self-efficacy, less harsh parenting practices, better child behavior, and a more positive parent-child relationship. We conclude that EE and attributions are potential explanatory variables to be considered in the development of preventative and early intervention strategies for families with a parent with schizophrenia or other psychotic disorder. Blame and warmth are modifiable factors that could be targeted within family and parenting interventions.

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

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

Young adults' dynamic relationships with their families in early psychosis: Identifying relational strengths and supporting relational agency

OBJECTIVES

Most existing research on the family context of psychosis focuses on the 'burden' of caring for people experiencing psychosis. This research is the first to ask young people experiencing early psychosis to 'map' and describe their experiences and understandings of their family relationships, and how they have related to their psychosis and recovery.

DESIGN

The research took an inductive, multimodal hermeneutic-phenomenological approach (Boden, Larkin & Iyer, 2019, Qual. Res. Psychology, 16, 218-236; Boden & Larkin, 2020, A handbook of visual methods in psychology, 358-375).

METHOD

Ten young adults (18-23), under the care of early intervention in psychosis services in the UK, participated in an innovative relational mapping interview (Boden, Larkin & Iyer, 2018), which invited participants to draw a subjective 'map' of their important relationships. This visual methodology enables subtle, complex, ambivalent, and ambiguous aspects of the participants' experiences to be explored.

RESULTS

Findings explore the participants' accounts of how they love, protect, and care for their families; how they wrestle with family ties as they mature; and their feelings about talking about their mental health with loved ones, which was typically very difficult.

CONCLUSIONS

This paper advances understanding of recovery in psychosis through consideration of the importance of reciprocity, and the identification and nurturance of relational strengths. The capacity of a young person to withdraw or hold back when trying to protect others is understood as an example of relational agency. The possibility for extending strengths-based approaches and family work within the context of early intervention in psychosis services is discussed.

PRACTITIONER POINTS

Young adults experiencing early psychosis may benefit from support to identify their relational strengths and the opportunities they have for reciprocity within their family structures, where appropriate. Relational motivations may be important for a range of behaviours, including social withdrawal and non-communication. Services may benefit from exploring the young person's relational context and subjective meaning-making in regard to these actions. Young adults experiencing early psychosis may benefit from opportunities to make sense of their family dynamics and how this impacts on their recovery. Attachment-based and relationally oriented interventions that increase trust and openness, and reduce feelings of burdensomeness are likely to support family functioning as well as individual recovery.

The implementation of family-focused practice in adult mental health services: A systematic review exploring the influence of practitioner and workplace factors

There is increased recognition of the need for greater and more appropriate support to be offered to families in which a parent experiences mental illness and has dependent children. One way of meeting this need is for adult mental health services to take a more family-focused approach. However, there are recognized difficulties in facilitating family-focused practice (FFP). The current review systematically synthesized quantitative and qualitative literature of practitioner perspectives and experiences of FFP in adult mental health settings to identify modifiable factors associated with its successful implementation. Five databases were searched systematically leading to the inclusion and quality assessment of 19 papers, ten of which were quantitative and nine qualitative. Analysis was guided by a narrative synthesis approach. Factors shown to influence FFP functioned at both practitioner and workplace levels and included personal attitudes, beliefs about job role, and perceptions of workplace support. Practitioners who felt that a family-focussed approach was inappropriate or detrimental to service users or outside of their remit as mental health professionals were less likely to adopt this approach. For those who saw the potential benefits of FFP, lack of confidence in their ability to deliver such an approach and lack of training can be barriers, as can lack of support and resources within services. This review highlights the need for actions to boost the awareness of adult mental health practitioners working with parents and to increase their confidence. It also makes the case for broader organizational support if family-focussed practice is to be implemented successfully.

The effect of family environment and psychiatric family history on psychosocial functioning in first-episode psychosis at baseline and after 2 years

The aim of the present study was to evaluate the contribution of family environment styles and psychiatric family history on functioning of patients presenting first-episode psychosis (FEP). Patients with FEP and healthy controls (HC) were assessed at baseline and after 2 years. The Functional Assessment Short Test (FAST) was used to assess functional outcome and the Family Environment Scale (FES) to evaluate family environment. Linear regressions evaluated the effect that family environment exerts on functioning at baseline and at 2-year follow-up, when FEP patients were diagnosed according to non-affective (NA-PSYCH) or affective psychoses (A-PSYCH). The influence of a positive parents' psychiatric history on functioning was evaluated through one-way between-groups analysis of covariance (ANCOVA) models, after controlling for family environmental styles. At baseline, FEP patients presented moderate functioning impairment, significantly worse than HC (28.65±16.17 versus 3.25±7.92; p<0.001, g = 1.91). At 2-year follow-up, the functioning of NA-PSYCH patients was significantly worse than in A-PSYCH (19.92±14.83 versus 12.46±14.86; p = 0.020, g = 0.50). No specific family environment style was associated with functioning in FEP patients and HC. On the contrary, a positive psychiatric father's history influenced functioning of FEP patients. After 2 years, worse functioning in NA-PSYCH patients was associated with lower rates of active-recreational and achievement orientated family environment and with higher rates of moral-religious emphasis and control. In A-PSYCH, worse functioning was associated with higher rates of conflict in the family. Both family environment and psychiatric history influence psychosocial functioning, with important implications for early interventions, that should involve both patients and caregivers.

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.

Identifying clinical clusters with distinct trajectories in first-episode psychosis through an unsupervised machine learning technique

The extreme variability in symptom presentation reveals that individuals diagnosed with a first-episode psychosis (FEP) may encompass different sub-populations with potentially different illness courses and, hence, different treatment needs. Previous studies have shown that sociodemographic and family environment factors are associated with more unfavorable symptom trajectories. The aim of this study was to examine the dimensional structure of symptoms and to identify individuals' trajectories at early stage of illness and potential risk factors associated with poor outcomes at follow-up in non-affective FEP. One hundred and forty-four non-affective FEP patients were assessed at baseline and at 2-year follow-up. A Principal component analysis has been conducted to identify dimensions, then an unsupervised machine learning technique (fuzzy clustering) was performed to identify clinical subgroups of patients. Six symptom factors were extracted (positive, negative, depressive, anxiety, disorganization and somatic/cognitive). Three distinct clinical clusters were determined at baseline: mild; negative and moderate; and positive and severe symptoms, and five at follow-up: minimal; mild; moderate; negative and depressive; and severe symptoms. Receiving a low-dose antipsychotic, having a more severe depressive symptomatology and a positive family history for psychiatric disorders were risk factors for poor recovery, whilst having a high cognitive reserve and better premorbid adjustment may confer a better prognosis. The current study provided a better understanding of the heterogeneous profile of FEP. Early identification of patients who could likely present poor outcomes may be an initial step for the development of targeted interventions to improve illness trajectories and preserve psychosocial functioning.

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.

Clients' Preferences for Family Involvement and Subsequent Family Contact Patterns Within OnTrackNY Early Psychosis Services

OBJECTIVE

Little is known about clients' preferences for family involvement and subsequent family contact in naturalistic, community-based coordinated specialty care (CSC) settings. The study's primary goal was to characterize clients' preferences and longitudinal patterns of family contact with providers across the OnTrackNY network in New York.

METHODS

Clinical administrative data collected at 3-month intervals and spanning 21 OnTrackNY CSC sites were used to analyze the preferences of 761 clients at baseline (unconditional involvement, conditional involvement, or no involvement) and patterns of family contact with program staff (always, sometimes, never, or early discharge) and their correlates during the initial 12-month service period. Data from clients discharged before 12 months were included for comparison.

RESULTS

At baseline, most clients requested some form of family involvement (unconditional, 59%; conditional, 35%; and none, 6%). Within each 3-month assessment period, rates of family contact ranged from 73% to 84%. Variables associated with both client preferences and contact patterns included baseline insurance status, housing status, race, frequency of family contact, and employment. Clients' preferences for no or conditional family involvement were associated with higher rates of early discharge (i.e., before 1 year).

CONCLUSIONS

Structuring family involvement around clients' preferences did not appear to negatively affect family contact, and for some clients, it seemed to bolster such contact. Additional mixed-methods research is needed to deepen the understanding of the contexts and reasoning underlying both client preferences for family involvement and subsequent levels of family contact.

The effects of the COVID-19 outbreak and measures in patients with a pre-existing psychiatric diagnosis: A cross-sectional study

Background COVID-19 has seriously affected physical and mental health world-wide,both due to spreading of the virus and due to the socially restrictive measures most governments have enforced. Increased anxiety, stress and depressive symptoms have been widely reported in the general population. The current study investigated the effects of COVID and the restrictive measures in the Netherlands on stress, anxiety and loneliness in patients with a pre-existing psychiatric disorder. Methods 189 patients with a pre-existing psychiatric disorder treated at the University Medical Center Utrecht (UMCU) provided consent to participate in an electronically provided survey. Questionnaires on anxiety, depressive symptoms, worry, stress and general health were completed by 148 participants. Results All patients reported heightened distress as well as the presence of depressive symptoms and loneliness during the initial phase of the restrictive measures. Patients could be divided into two major subgroups with either psychotic disorder (n = 71) and affective disorder (n = 86). Patients with affective disorders were more affected by the outbreak and accompanying socially restrictive measures than patients with psychotic disorders. Conclusions Our findings indicate negative mental health effects of the global COVID-19 pandemic and the restrictive measures in a particularly vulnerable population, with differential effects on diagnostic groups.

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.

Predictors of criticism and emotional over-involvement in relatives of early psychosis patients

Mechanisms underlying the manifestation of relatives’ expressed emotion (EE) in the early stages of psychosis are still not properly understood. The present study aimed to examine whether relatives’ psychological distress and subjective appraisals of the illness predicted EE dimensions over-and-above patients’ poor clinical and functional status. Baseline patient-related variables and relatives attributes comprising criticism, emotional over-involvement (EOI), psychological distress, and illness attributions were assessed in 91 early psychosis patients and their respective relatives. Relatives were reassessed regarding EE dimensions at a 6-month follow-up. Relatives’ psychological distress and illness attributions predicted criticism and EOI over-and-above patients’ illness characteristics at both time points. Relatives’ increased levels of anxiety, attributions of blame toward the patients, an emotional negative representation about the disorder, and decreased levels of self-blame attributions predicted EE-criticism at baseline. Relatives’ anxiety and negative emotional representation of the disorder were the only significant predictors of EE-criticism at follow-up, whereas anxiety, attributions of control by the relative and an emotional negative representation about the disorder predicted EE-EOI both at baseline and follow-up assessments. Understanding the components that comprise and maintain EE attitudes should guide early psychosis caregivers in family interventions, enhancing proper management of psychological distress and reduction of negative appraisals about the illness. The prevention of high-EE attitudes over time in a sensitive period such as early psychosis might be critical in shaping the health of caregivers and the outcome of the affected relatives.

A systematic review of online interventions for families of patients with severe mental disorders

BACKGROUND

Several studies show the effectiveness of face-to-face interventions with families in improving the prognosis of patients with severe psychiatric disorders and their relatives; however, the effectiveness of online interventions is poorly understood. The current study aims to provide an overview of evidence for the effectiveness of online treatments (web/app) for patients with severe psychiatric disorders and their families.

METHOD

We performed a systematic review of online treatments for informal family caregivers of patients with a severe psychiatric disorder. The study psychological interventions had to have been administered in an exclusively online format (app, internet) and aimed at families of patients with severe mental disorder (at least one of first episode psychosis, schizophrenia, schizoaffective, bipolar disorder, and psychotic disorder).

RESULTS

Of a total of 1331 articles, we identified 9 viable studies; 4 randomized clinical trials, and 5 nonrandomized clinical studies. The present study is the first systematic review in this area. Online interventions were well accepted, with good adherence and satisfaction among the caregivers and patients and improved the symptoms of both caregivers and patients.

LIMITATIONS

Clinical and methodological diversity of the studies.

CONCLUSIONS

Burden improved, and perceived stress decreased in families. Moreover, the severity of positive symptoms decreased and fewer hospitalizations were recorded in patients than in the control group. Therefore, online interventions are a promising therapeutic approach for patients with severe mental disorder and their families. However, more studies-particularly randomized clinical trials-are needed in this area.

The mechanisms and processes of connection: developing a causal chain model capturing impacts of receiving recorded mental health recovery narratives

BACKGROUND

Mental health recovery narratives are a core component of recovery-oriented interventions such as peer support and anti-stigma campaigns. A substantial number of recorded recovery narratives are now publicly available online in different modalities and in published books. Whilst the benefits of telling one's story have been investigated, much less is known about how recorded narratives of differing modalities impact on recipients. A previous qualitative study identified connection to the narrator and/or to events in the narrative to be a core mechanism of change. The factors that influence how individuals connect with a recorded narrative are unknown. The aim of the current study was to characterise the immediate effects of receiving recovery narratives presented in a range of modalities (text, video and audio), by establishing the mechanisms of connection and the processes by which connection leads to outcomes.

METHOD

A study involving 40 mental health service users in England was conducted. Participants were presented with up to 10 randomly-selected recovery narratives and were interviewed on the immediate impact of each narrative. Thematic analysis was used to identify the mechanisms of connection and how connection leads to outcome.

RESULTS

Receiving a recovery narrative led participants to reflect upon their own experiences or those of others, which then led to connection through three mechanisms: comparing oneself with the narrative and narrator; learning about other's experiences; and experiencing empathy. These mechanisms led to outcomes through three processes: the identification of change (through attending to narrative structure); the interpretation of change (through attending to narrative content); and the internalisation of interpretations.

CONCLUSIONS

This is the first study to identify mechanisms and processes of connection with recorded recovery narratives. The empirically-based causal chain model developed in this study describes the immediate effects on recipients. This model can inform selection of narratives for use in interventions, and be used to support peer support workers in recounting their own recovery narratives in ways which are maximally beneficial to others.

Family processes and duration of untreated psychosis among US Latinos

AIM

Little is known about family processes and treatment seeking among Latinos with first-episode psychosis (FEP) living in the United States. This study examined family processes prior to treatment and their relation to duration of untreated psychosis (DUP) among Latinos with FEP and their family caregivers.

METHODS

Thirty-three Latinos with FEP and their low-acculturated family caregivers (n = 33) participated in qualitative semi-structured interviews focused on treatment-seeking experience and family relationships. Transcripts were analysed using thematic analysis and themes were grouped based on short (n = 18) or long (n = 15) DUP.

RESULTS

Findings revealed differences based on DUP length. Patients with short DUP had stronger family relationships characterized by open communication and disclosure of symptoms that facilitated awareness and direct action by family caregivers. However, patients with long DUP had more troubled family relationships that often challenged early treatment seeking.

CONCLUSIONS

Findings highlight the relevance of family context in the provision of early treatment for Latinos with FEP. Family-based services are needed that increase awareness of symptoms and provide families with support that can facilitate ongoing patient treatment during this critical period.

The digital revolution and its impact on mental health care

The digital revolution is evolving at an unstoppable pace. Alongside the unprecedented explosion of digital technology facilities and systems, mental health care is under greater pressure than ever before. With its emphasis on big data, computing power, mobile technology, and network information, digital technology is set to transform health care delivery. This article reviews the field of digital health technology assessment and intervention primarily in secondary service mental health care, including the barriers and facilitators to adopting and implementing digitally mediated interventions in service delivery. We consider the impact of digitally mediated communication on human interaction and its potential impact on various mental states such as those linked to mood, anxiety but also well-being. These developments point to a need for both theory- and data-driven approaches to digital health care. We argue that, as developments in digital technology are outpacing the evaluation of rigorous digital health interventions, more advanced methodologies are needed to keep up with the pace of digital technology development. The need for co-production of digital tools with and for people with chronic and mental health difficulties, and implications of digital technology for psychotherapy practice, will be central to this development. PRACTITIONER POINTS: Mental health problems are one of the main causes of global and societal burden and are a growing public health. People with mental health problems around the world have limited, if any, chance of accessing psychological help at all. Technological innovations and solutions are being considered in an attempt to address the size and scale of the mental health crisis worldwide. Digital platforms allow people to self-monitor and self-manage in a way that face-to-face/paper-based methods of assessment have up until now not allowed. We provide examples of digital tools that are being developed and used in the secondary setting and identify a number of challenges in the digital health field that require careful consideration.

Caregiving processes and expressed emotion in psychosis, a cross-cultural, meta-analytic review

The construct of Expressed Emotion (EE) is a reliable predictor of relapse in psychotic disorders globally. However, cultural differences in the level and manifestation of EE have been reported. This review was conducted in line with PRISMA guidelines to demonstrate the distribution of EE and its domains cross-culturally as well as its relationship with relapse in psychosis. Ninety-six studies reported global EE scores and/or separate EE domains amongst caregivers of a family member with psychosis and used the Camberwell Family Interview (CFI) to measure EE. In the meta-analysis (k = 34, n = 1982), exposure to high EE was indicative of a 95% increased likelihood of relapse compared to low EE. However, no significant effect of geographical region on global EE scores (high/low) or EE domains was found. Several adjustments to the scoring of the CFI were highlighted based on cultural norms, particularly relevant to the domains of emotional over-involvement, warmth and criticism. Although this made meaningful quantitative comparisons across studies difficult, it nonetheless highlighted cultural considerations that need to be taken into account when interpreting EE and understanding its relationship to clinical outcomes. There is not a universal normative EE experience, with cultural variation in the scoring and interpretation of EE existing as evidenced by adjusted cut off scores and conceptualisation of EE constructs. Thus, it is important for clinical practitioners to have an awareness of different cultural norms in relation to caregiving and care receiving behaviours, which can inform adaptations to clinical interventions in multicultural settings.

Are family warmth and positive remarks related to outcomes in psychosis? A systematic review

BACKGROUND

Affective attitudes and behaviours manifested within the family environment have been characterised as expressed emotion (EE). High EE environments have been robustly shown to put psychosis patients at a greater risk of relapse compared with low EE exposure. Positive EE dimensions (warmth; positive remarks) have received far less attention than negative EE dimensions such that EE has become synonymous with a negative family atmosphere; the predictive value of positive EE dimensions is largely ignored. A systematic review examining the relationship between positive family EE and outcomes in psychosis is needed.

METHODS

A systematic search was conducted. Studies reporting bias and study quality were assessed.

RESULTS

A total of 2368 studies were identified. Of these, 27 met eligibility criteria reporting outcomes including relapse, symptomatology, social functioning and life satisfaction. Relapse was the most commonly measured outcome. Stronger evidence emerged for the association between EE warmth and outcomes compared with EE positive remarks, with effects mostly evident in the early phase of psychosis. Evidence for protective effects of warmth on relapse was found up to 9 months follow-up. No effects were evident between positive remarks and relapse. Studies assessing symptom outcomes showed inconsistent findings. Evidence for an association with social functioning was evident, primarily in at risk mental states. Warmth and positive remarks predicted life satisfaction.

CONCLUSIONS

The positive aspects of EE require further investigation with longitudinal research designs. Clinical interventions should focus not only on reducing negative aspects of EE but also foster warmth within families in the context of psychosis.

Neural responses to criticism and praise vary with schizotypy and perceived emotional support

Schizotypy is a latent organisation of a cluster of personality styles, such as magical thinking, disorganisation and anhedonia, which are in the normal range of the psychosis continuum. Schizotypy relates to an increased likelihood of perceiving expressed emotion (EE). EE is characterised by criticism, rejection, and emotional over-involvement and less warmth from a close relative. Neuroimaging studies have found normal frontal lobe activation to EE-criticism in people with high schizotypy. Alternatively, electroencephalography measures emotion processing, such as frontal theta power and occipital alpha power. Frontal theta power responds to cognitive and affective processes and occipital alpha power denotes less consciousness and emotional attention. This study aimed to determine the relation of these electroencephalography responses during criticism and praise to perceived emotional support. Participants (n = 32) representing the full (low-to-high) range of positive schizotypy listened to and rated the self-relevance of EE-like criticism and praise and affectively neutral comments while undergoing electroencephalography. Participants completed self-report measures of schizotypy, depression and anxiety. A subset of those with a high positive schizotypy score (n = 22) completed a measure of perceived EE - lack of emotional support. Higher perceived EE - lack of emotional support correlated with lower frontal theta power and lower occipital alpha power during criticism and praise in schizotypal participants. The findings suggest that these neural responses may relate to less perceived emotional support in people with high schizotypy, of which a reduction of frontal theta power denotes less emotional arousal and lower occipital alpha power denotes more alertness to emotional information may relate to less perceived emotional support in people with high schizotypy.

Caregivers of individuals with schizophrenia: who are they and what are their challenges?

PURPOSE OF REVIEW

To better understand the overall burden of schizophrenia, we aimed to explore informal caregivers' experiences by evaluating the current evidence on caregiver and patient characteristics, the type of care provided by caregivers, and the impacts of caregiving on caregivers' lives.

RECENT FINDINGS

Caregivers provide direct care, assistance with activities of daily living, and emotional, social, and financial support to individuals with schizophrenia. Increased duration of illness and of care, severe or persistent schizophrenia symptoms, criticism of the care recipient, financial burden, and patient disability intensify caregiver burden. Caregivers of individuals with persistent symptoms often feel overwhelmed, stressed, drained, burdened, frustrated, or angry. Financial impacts of caregiving include treatment costs for care recipients, providing financial support, and lost productivity and income. Depression and anxiety are common health impacts for caregivers, who also have increased physical healthcare resource use relative to healthy controls. Caregiver burden is reduced by formal support programs to improve caregivers' stress management and coping skills and informal sources of social support.

SUMMARY

Targeted efforts to improve access to care and provide additional support for caregivers are needed to alleviate caregiver burden and improve outcomes for individuals with schizophrenia.

Predictors and moderators of burden of care and emotional distress in first-episode psychosis caregivers: results from the GET UP pragmatic cluster randomised controlled trial

AIMS

First-episode psychosis (FEP) is a major life event and can have an adverse impact on the diagnosed individual and their families. The importance of intervening early and providing optimal treatments is widely acknowledged. In comparison to patient groups, literature is scarce on identifying treatment predictors and moderators of caregiver outcomes. This study aimed to identify pre-treatment characteristics predicting and/or moderating carer outcomes, based on data from a multi-element psychosocial intervention to FEP patients and carers (GET-UP PIANO trial).

METHODS

Carer demography, type of family relationship, patient contact hours, pre-treatment carer burden, patient perceptions of parental caregiving and expressed emotion (EE) were selected, a priori, as potential predictors/moderators of carer burden and emotional distress at 9 months post treatment. Outcomes were analysed separately in mixed-effects random regression models.

RESULTS

Analyses were performed on 260 carers. Only patient perceptions of early maternal criticism predicted reports of lower carer burden at follow-up. However, multiple imputation analysis failed to confirm this result. For treatment moderators: higher levels of carer burden at baseline yielded greater reductions in carer emotional distress at follow-up in the experimental group compared with treatment as usual (TAU). Higher levels of perceived EE moderated greater reductions in carer reports of tension in experimental group, compared with TAU, at follow-up. In younger caregivers (<51 years old), there were greater reductions in levels of worry during the baseline to follow-up period, within the experimental group compared with TAU.

CONCLUSION

The study failed to identify significant treatment predictors of FEP carer outcomes. However, our preliminary findings suggest that optimal treatment outcomes for carers at first episode might be moderated by younger carer age, and carers reporting higher baseline levels of burden, and where patients perceive higher levels of negative effect from caregivers.

Affective and physiological reactivity to emotional comments in individuals at elevated risk for psychosis

BACKGROUND

Individuals with schizophrenia are at increased risk of relapse when they live in highly critical (i.e., high expressed emotion; EE) family environments. It remains less clear, however, how individuals at elevated risk for a psychotic disorder react to the social stress of EE. Here we examined whether individuals at elevated risk for developing schizophrenia report greater subjective changes in affect and have increased physiological reactivity after hearing critical, praising and neutral comments.

METHOD

Measures of heart rate, heart rate variability, skin conductance, and self-reported affective ratings were used to assess differential responses to EE-type stimuli in 38 individuals at elevated-risk for psychosis and 38 low-risk controls.

RESULTS

The elevated-risk group and low-risk controls, did not differ in their initial affective and physiological reactivity to criticism. However, during the recovery period following the criticism, the elevated-risk group demonstrated greater heart rate activation. They also showed more sensitivity to praise. Although elevated-risk participants initially had higher baseline levels of negative affect and heart rate, following praise, these levels reduced and became indistinguishable from the levels of low-risk controls.

CONCLUSIONS

These findings suggest that at-risk individuals may have more difficulty recovering from criticism than their self-report data might suggest. They may also derive physiological and affective benefits from praise. Important clinical implications of these findings are discussed.

An experimental investigation of the impact of critical and warm comments on state paranoia in a non-clinical sample

BACKGROUND AND OBJECTIVES

Interpersonal stress is key to the development and maintenance of paranoia. Much attention has been given to the impact of interpersonal stressors, such as criticism, on outcomes in psychosis. Less attention has been given to the potentially protective effects of positive interpersonal factors. This study tested experimentally whether criticism and warm comments elicited changes in state paranoia. Whether warm comments provided protective effects when participants faced subsequent social exclusion was also examined.

METHOD

A nonclinical sample (N = 97) was randomised to criticism, warm comments, or neutral comments conditions. Participants then played a virtual ball game (Cyberball), during which they were systematically excluded from the game. State paranoia was measured before and after the affective stimuli and after social exclusion. Self-esteem and trait paranoia were also measured.

RESULTS

Paranoia levels increased following exposure to criticism (p = .011). Paranoia was not significantly lower following exposure to warm comments (p = .203). Warm comments did not provide protection against the effects of subsequent social exclusion. The warm comments condition was the only condition in which significant increases in paranoia were seen following social exclusion (p = .004).

LIMITATIONS

Use of a non-clinical sample limits generalisation to clinical populations.

CONCLUSIONS

Criticism is sufficient to elicit increases in paranoia in non-clinical participants. Warm comments are insufficient to significantly reduce paranoia or provide protective effects against subsequent negative interpersonal experiences, highlighting the need to balance therapeutic warmth with amelioration of social stressors in paranoia.

"Worried about relapse": Family members' experiences and perspectives of relapse in first-episode psychosis

BACKGROUND

The purpose of this study was to gain an in-depth understanding on the subject of relapse from the perspectives of family members of young people receiving services for a first-episode psychosis (FEP).

METHODS

A qualitative descriptive approach, using focus group methods, was used to elicit experiences, understandings, and knowledge of relapse in FEP. Family members were recruited from 4 specialized early intervention programmes for psychosis in Canada. A total of 24 (6 male, 18 female) family members participated in the study. Thematic analysis was used to examine the data.

RESULTS

The core underlying theme in all focus groups was worrying about relapse, which was often accompanied by significant levels of fear and anxiety, and was influenced by: (1) impact of an episode of psychosis; (2) limited confidence in recognizing and coping with relapse; (3) unmet needs for coping skills and emotional support and (4) unmet needs regarding frequency and continuity of communication with clinicians.

CONCLUSIONS

Family members' unmet needs for relapse-focused education, support and communication with service providers and peers, can have a negative impact on relapse prevention. Addressing family members' education and support needs in a tailored manner (including preferences for types of peer support) can contribute positively to their confidence and ability to recognize and respond to relapse. This can help reduce fear and anxieties about relapse, and positively influence the ability to function as caregivers. Future research should focus on best approaches for providing education, sustained contact with the clinical team and family peer support.

Caregiver correlates of patient-initiated violence in early psychosis

Patient-initiated violence may pose a significant risk to the strength and longevity of informal caregiving relationships in psychosis. We aimed to assess caregiver reports of patient-initiated violence in early psychosis and to examine the relationship between violent incidents and appraisals of caregiving, perceived mental wellbeing in caregivers and Expressed Emotion (EE) in the caregiving relationship. Eighty psychosis caregivers were recruited via Early Intervention (EI) psychosis services in London, United Kingdom. Caregivers were questioned about their experiences of patient-initiated violence during the semi-structured Camberwell Family Interview, and completed the Experience of Caregiving Inventory and the RAND SF-36 health survey in a cross-sectional experimental design. One third of the sample reported at least one incident of patient-initiated violence. Reports of violence were associated with poorer mental wellbeing scores amongst caregivers and more negative appraisals of caregiving. Patient-initiated violence also correlated with greater criticism and hostility expressed towards patients, and a rating of high EE in caregiver reports. The results underscore the need to ask explicitly and routinely about the physical safety of caregivers looking after someone with psychosis. Families should be directed towards appropriate interventions to help manage any risk of violence and the likely negative impact on the caregiving relationship.

Sensitivity to criticism and praise predicts schizotypy in the non-clinical population: The role of affect and perceived expressed emotion

BACKGROUND

Schizotypy represents a cluster of personality traits consisting of magical beliefs, perceptual aberrations, disorganisation, and anhedonia. Schizotypy denotes a vulnerability for psychosis, one reason being psychosocial stress. High expressed emotion (EE), a rating of high criticism, hostility, and emotional over-involvement from a close relative, denotes psychosocial stress and vulnerability to psychosis, and is associated with schizotypy. This study aimed to decipher the relationship of schizotypy to perceived criticism and perceived praise in terms of affect and perceived EE.

METHODS

Ninety-eight healthy participants listened to short audio-clips containing criticism, praise, and neutral comments from a stranger, and evaluated them in terms of the comments' arousal and personal relevance. Participants also answered self-report questionnaires of schizotypy, depression, mood, and perceived EE. Correlational analyses tested the relationship between schizotypy and the evaluations of criticism and praise. Mediation analyses then tested whether depression, positive mood, and perceived EE explained these relationships.

RESULTS

Greater relevance of standard criticism correlated with higher positive schizotypy. This association was fully mediated by high depression and perceived irritability from a close relative. Lower relevance of standard praise correlated with higher cognitive disorganisation (another schizotypal trait). This relationship was partially mediated by low positive mood and high perceived intrusiveness from a close relative.

CONCLUSION

Greater perceived criticism and lower perceived praise predict schizotypy in the healthy population. Affect and interpersonal sensitivity towards a close relative explain these relationships, such that depression increases perceived criticism, and positive mood increases perceived praise. Perceived EE defines the interpersonal nature of schizotypy.

Family functioning in youth at-risk for serious mental illness

BACKGROUND

There is evidence that family functioning can be impaired in families of individuals with schizophrenia, first-episode psychosis, bipolar disorder, and recurrent depression, which are considered to be serious mental illnesses (SMI). Poor family functioning is one of the predictors of the course of SMI. However, it is unclear if poor family functioning is a result of illness, or conversely if poor family leads to higher risk of illness. Nonetheless, family functioning may be impaired even before the onset of illness, and little is known about earlier stages of risk and the importance of the family environment for youth at-risk for SMI.

OBJECTIVE

The present study aimed to examine differences in family functioning in a sample of youth at-risk of SMI across different clinical stages compared to healthy controls (HCs).

METHODS

Family functioning was evaluated with the Family Adaptability and Cohesion Evaluation Scales-IV (FACES-IV) for 41 non-help seeking youth with risk factors for SMI (Stage 0), 52 help-seeking youth with early mood and anxiety symptoms and distress (Stage 1a), 108 youth with an attenuated psychiatric syndrome (Stage 1b), and 42 HCs.

RESULTS

Results from multivariate linear regression analyses showed that participants in Stage 1a and Stage 1b significantly differ from participants in Stage 0 and HCs on most of the family functioning scales. However, these results were statistically but not clinically significant as the percentile values for each group fell within the same clinical ranges. The only clinical difference was that participants in stages 1a and 1b were somewhat less satisfied with their family compared to healthy controls and stage 0 participants.

CONCLUSIONS

An examination of group mean values demonstrated no difference in family functioning between the different groups with all groups in the healthy functioning range. However, family satisfaction is lower in youth at-risk for SMI who present with early signs of mood, anxiety or subthreshold psychotic symptoms than other participants. Early family psychoeducational interventions could be beneficial to improve family functioning.

Understanding the experience of "burnout" in first-episode psychosis carers

BACKGROUND

The first onset of psychosis can exert a significant negative impact on the functioning and positive wellbeing of family carers. Carer reports of "burnout" have recently been recorded in early psychosis carers, though the literature is scarce detailing our understanding of how burnout relates to the primary experience of caregiving. The current study investigated reports of burnout and its relationship with beliefs about caregiving and wellbeing in a large group of early psychosis carers who were routinely assessed within an early intervention team.

METHODS AND MATERIALS

Using a cross-sectional design, 169 early psychosis carers completed the Maslach Burnout Inventory alongside measures of caregiving experiences, affect and wellbeing.

RESULTS

The mean illness length for patients with psychosis was 18 months. Their mean age was 24.4 years and most was male (65%). The majority of carer participants were parental caregivers and living with their relative with psychosis. Across the three key burnout dimensions, 58% of the sample reported high levels of emotional exhaustion; 31% endorsed high levels of depersonalization; and 43% reported low levels personal accomplishment. The most severe level of burnout, reflecting elevated rates across all three dimensions, was observed in 16% of the sample. Carer burnout was positively associated with negative caregiving experiences (i.e. burden), poor affect, and reduced levels of positive wellbeing and perception of being in good health.

CONCLUSIONS

Reports by early psychosis carers of exhaustion, feeling inadequate and expressing negativity towards the relative they care for is not uncommon and are closely associated with their overall negative appraisals of caregiving. The results underscore the importance of developing targeted interventions during the early phase, which are designed to reduce the development and entrenchment of burnout responses in carers, but to also mitigate its negative sequelae.

Psychological Flexibility as a Buffer against Caregiver Distress in Families with Psychosis

Background: Research has shown that caregivers of persons with psychosis play an invaluable role in recovery, but unfortunately, often report high levels of distress. While cognitive models of caregiver distress have been well-supported, there is still limited knowledge of the psychological factors involved. Recent advances in cognitive behavioral therapy seem to converge on the importance of acceptance- and mindfulness based processes.

Aim: To examine the impact of psychological flexibility on caregiver distress in the early phases of psychosis, while controlling for known predictors of caregiver distress.

Method: Within a cross-sectional design, 101 caregivers of 38 persons with first-episode psychosis in a clinical epidemiological sample completed a series of self-report measures.

Results: A linear mixed model analysis found that, after controlling for caregiver socio-demographic factors, service user symptoms, drug use and global functioning, psychological flexibility was a significant predictor of caregiver distress.

Conclusion: Greater level of psychological flexibility in caregivers, seems to be related to lower levels of caregiver distress. This finding corresponds to studies within a broad range of emotional disorders. There may be important clinical implications in terms of facilitating the process of acceptance through interventions from the ‘third-wave’ or contextual cognitive behavioral therapies.

Perceived criticism predicts outcome of psychotherapy for panic disorder: Replication and extension

OBJECTIVE

We tested the relation of perceived criticism (PC) from a parent or spouse/romantic partner to outcome of psychotherapy for panic disorder (PD).

METHOD

Participants were 130 patients with PD (79% with agoraphobia) who received 24 twice-weekly sessions of panic-focused psychodynamic psychotherapy, cognitive-behavioral therapy, or applied relaxation therapy. Patients were predominantly White (75%), female (64%), and non-Hispanic (85%). At baseline, Week 5 of treatment, termination, and at 6- and 12-month follow-up, patients rated PC from the relative with whom they lived. Independent evaluators assessed the severity of PD at baseline, Weeks 1, 5, and 9 of treatment, termination, and the 2 follow-up points. Data were analyzed with piecewise (treatment phase, follow-up phase) latent growth curve modeling.

RESULTS

The latent intercept for PC at baseline predicted the latent slope for panic severity in the follow-up (p = .04) but not the active treatment phase (p = .50). In contrast, the latent intercept for PD severity at baseline did not predict the latent slope on PC in either phase (ps ≥ .29). Nor did the slopes of PC and PD severity covary across treatment (p = .31) or follow-up (p = .13). Indeed, PC did not change significantly across treatment (p = .45), showing the stability of this perception regardless of significant change in severity of patients' PD (p < .001).

CONCLUSIONS

Because PC predicts worse long-term treatment outcome for PD, study findings argue for interventions to address perceived criticism in treatment. (PsycINFO Database Record

Family Burden, Emotional Distress and Service Satisfaction in First Episode Psychosis. Data from the GET UP Trial

Background: Literature has documented the role of family in the outcome of chronic schizophrenia. In the light of this, family interventions (FIs) are becoming an integral component of treatment for psychosis. The First Episode of Psychosis (FEP) is the period when most of the changes in family atmosphere are observed; unfortunately, few studies on the relatives are available.

Objective: To explore burden of care and emotional distress at baseline and at 9-month follow-up and the levels of service satisfaction at follow-up in the two groups of relatives (experimental treatment EXP vs. treatment as usual TAU) recruited in the cluster-randomized controlled GET UP PIANO trial.

Methods: The experimental treatment was provided by routine public Community Mental Health Centers (Italian National Health Service) and consisted of Treatment as Usual plus evidence-based additional treatment (Cognitive Behavioral Therapy for psychosis for patients, Family Intervention for psychosis, and Case Management). TAU consisted of personalized outpatient psychopharmacological treatment, combined with non-specific supportive clinical management and informal support/educational sessions for families. The outcomes on relatives were assessed by the Involvement Evaluation Questionnaire (IEQ-EU), the General Health Questionnaire (GHQ-12), and the Verona Service Satisfaction Scale (VSSS-EU). Differences within and between groups were evaluated.

Results: At baseline, 75 TAU and 185 EXP caregivers were assessed. In the experimental group 92% of relatives participated in at least 1 family session. At follow-up both groups experienced improvement in all IEQ and GHQ items, but caregivers belonging to the EXP arm experienced a significantly greater change in 10 IEQ items (mainly pertaining to the “Tension” dimension) and in GHQ items. Due to the low sample size, a significant effectiveness was only observed for 2 IEQ items and 1 GHQ-12 item. With respect to VSSS data at follow-up, caregivers in the EXP arm experienced significantly greater satisfaction in 8 items, almost all pertaining to the dimensions “Relatives' Involvement” and “Professionals' Skills and Behavior.”

Conclusions: The Family intervention for psychosis delivered in the GET UP PIANO trial reduced family burden of illness and improved emotional distress and satisfaction with services. These results should encourage to promote FIs on caregivers of first-episode psychosis patients.

Relatives' expressed emotion, distress and attributions in clinical high-risk and recent onset of psychosis

It has been well-demonstrated that Expressed Emotion (EE) in caregivers of schizophrenia patients is related to their illness attributions, but little is known about relatives' cognitive and emotional appraisals at early stages of psychosis. This study examined differences on the relationships of EE with distress and illness attributions in 78 relatives of At-Risk Mental States (ARMS) and First-Episode of Psychosis (FEP) patients, and which of those variables better predicted EE. Criticism and Emotional Over-Involvement (EOI) were associated with distress and with several illness attributions in both groups. Anxiety was more strongly associated with criticism in ARMS than in FEP-relatives, and it was associated with EOI in the ARMS but not in the FEP-group. No differences on the relationships of EE with depression or attributions were found. Furthermore, distress and attributions of blame toward the patients predicted criticism. Attributions of control by the patient and emotional negative representation about the disorder predicted EOI. Findings highlight the need to focus on early family interventions that provide proper information and psychological support in accordance with the illness stage, to help relatives improve their understanding of the disorder, handle difficult thoughts and emotions, reduce negative appraisals, and prevent high-EE over the psychotic process.

Schizophrenia: Impact on Family Dynamics

In many societies, family members are now the primary caregivers of mental health patients, taking on responsibilities traditionally under the purview of hospitals and medical professionals. The impact of this shift on the family is high, having both an emotional and economic toll. The aim of this paper is to review the main changes that occur in family dynamics for patients with schizophrenia. The article addresses three central themes: (i) changes in the family at the onset of the disorder, (ii) consequences for family members because of their caregiver role, and (iii) family interventions aimed at improving the complex dynamics within the family. After analyzing and discussing these themes, it is observed that despite advances in the field, the viability of taking care of a patient with schizophrenia by the family remains a challenge. Improving care will require commitments from the family, the mental health service system, and local and national governments for greater investments to improve the quality of life of society in general and individuals with schizophrenia in particular.

Participants' perceived benefits of family intervention following a first episode of psychosis: a qualitative study

AIM

To explore the perceived benefits for patients and family members of psychoeducational family intervention following a first episode of psychosis.

METHODS

A qualitative exploratory study using data from interviews with 12 patients and 14 family members who participated in a psychoeducational multi- or single-family treatment programme. Semi-structured interviews were digitally recorded and transcribed verbatim with slight modifications, after which they were analysed by systematic text condensation.

RESULTS

Patients and family members reported benefits that could be classified in five categories: (i) developing insight and acceptance requires understanding of the fact that the patient has an illness, and recognizing the need for support; (ii) recognizing warning signs requires an understanding of early signs of deterioration in the patient; (iii) improving communication skills is linked to new understanding and better communication both within the family and in groups; (iv) Learning to plan and solve problems requires the ability to solve problems in new ways; (v) becoming more independent requires patients to take responsibility for their own life.

CONCLUSION

The study suggests that developing insight and acceptance, learning about warning signs, improving communications skills, learning to plan and solve problems, and becoming more independent are perceived as benefits of a psychoeducational family intervention.

An Interpersonal CBT Framework for Involving Relatives in Interventions for Psychosis: Evidence Base and Clinical Implications

Working with families in psychosis improves outcomes and is cost effective. However, implementation is poor, partly due to lack of a clear theoretical framework. This paper presents an interpersonal framework for extending the more familiar cognitive behavioral therapy model of psychosis to include the role of relatives' behavior in the process of recovery. A summary of the framework is presented, and the evidence to support each link is reviewed in detail. Limitations of the framework are discussed and further research opportunities highlighted. Clinical implications and a case example are described to show how the framework can be used flexibly to facilitate clinical practice. Our aim is to shift the focus of psychosocial interventions from an individualistic approach to treatment, towards greater involvement of relatives and recognition of the importance of the social environment on mental health.

The Vicious Cycle of Family Atmosphere, Interpersonal Self-concepts, and Paranoia in Schizophrenia-A Longitudinal Study

Recent cognitive models of paranoid delusions highlight the role of self-concepts in the development and maintenance of paranoia. Evidence is growing that especially interpersonal self-concepts are relevant in the genesis of paranoia. In addition, negative interpersonal life-experiences are supposed to influence the course of paranoia. As dysfunctional family atmosphere corresponds with multiple distressing dyadic experiences, it could be a risk factor for the development and maintenance of paranoia. A total of 160 patients with a diagnosis of schizophrenia were assessed twice within 12 months. Standardized questionnaires and symptom rating scales were used to measure interpersonal self-concepts, perceived family atmosphere, and paranoia. Data were analyzed using longitudinal cross-lagged structural equation models. Perceived negative family atmosphere was associated with the development of more pronounced negative interpersonal self-concepts 12 months later. Moreover, paranoia was related to negative family atmosphere after 12 months as well. As tests revealed that reversed associations were not able to explain the data, we found evidence for a vicious cycle between paranoia, family atmosphere, and interpersonal self-concepts as suggested by theoretical/cognitive model of paranoid delusions. Results suggest that broader interventions for patients and their caretakers that aim at improving family atmosphere might also be able to improve negative self-concepts and paranoia.

Impaired family functioning in psychosis and its relevance to relapse: a two-year follow-up study

BACKGROUND

The aim of the present study was to investigate whether dysfunctional family functioning contributes to relapse over a two-year follow-up period in patients experiencing their first episode of psychosis (FEP) and chronic patients with psychosis.

METHODS

The sample consisted of 100 remitted patients (50 FEP and 50 chronic) diagnosed with schizophrenia (82%) or bipolar disorder with most recent episode manic severe with psychotic features (18%) recruited from the Inpatient Psychiatric Unit of the University Hospital of Heraklion, Crete, Greece, and their family caregivers. Family functioning was assessed in terms of cohesion and flexibility (FACES-IV), expressed emotion (FQ), family burden (FBS) and caregivers' psychological distress (GHQ-28). Relapse was defined as patient rehospitalisation due to acute psychotic exacerbation, while number, length, and type of hospitalisations were also evaluated.

RESULTS

Dysfunctional family functioning in terms of cohesion and flexibility was not found to be a significant risk factor for relapse in psychosis. High expressed emotion, as indexed primarily by increased levels of criticism rather than emotional over-involvement, was associated with increased risk of relapse and shorter time to relapse (HR=0.48, 95% CI: 0.24, 0.98, p=0.043). Similarly, high levels of family burden were related to shorter time to relapse (HR=0.47, 95% CI: 0.23, 0.95, p=0.037), whereas there was no significant difference in survival curves based on caregivers' psychological distress. No significant interaction effect of illness chronicity was observed in the aforementioned associations.

CONCLUSION

These findings highlight caregivers' criticism and burden of care as long-term predictors of the course of psychosis from the early stages of the illness and later on. In contrast, unbalanced levels of cohesion and flexibility in the family, as well as caregivers' high emotional over-involvement and psychological distress do not appear to be factors that contribute to patient relapse. Family psychoeducational interventions focusing at ameliorating caregivers' negativity toward the patient, and easing the burden of care should be considered as means in reducing relapse.

Current maternal depression moderates the relation between critical expressed emotion in mothers and depressive symptoms in their adolescent daughters

Prior studies have examined critical expressed emotion (EE-Crit) in mothers in the intergenerational transmission of depression. However, the potential moderating effect of maternal depression diagnostic status in relation to EE-Crit and youth depressive symptoms has yet to be determined. A total of N=121 biological mother/daughter dyads that differed in maternal depression diagnostic status were recruited for the present study: (1) currently depressed mothers (current depression, n=29); (2) formerly depressed mothers (past depression, n=39); and (3) mothers free from any psychiatric history (healthy controls, n=53). Mothers were administered structured clinical interviews and completed self-report measures of EE-Crit and psychopathology, and daughters self-reported depressive symptoms. Results indicated no significant group differences in EE-Crit; however, current maternal depression status moderated EE-Crit such that the magnitude of the relation between EE-Crit and adolescent depressive symptoms was significantly greater in daughters of currently depressed mothers. These findings highlight the importance of considering current maternal depression, rather than a history of maternal depression, in relation to EE-Crit and adolescent depressive symptoms, providing impetus for future investigations.

Are the effects of duration of untreated psychosis socially mediated?

Investigation of possible mechanisms by which longer duration of untreated psychosis (DUP) could influence treatment outcomes has focused primarily on evidence for neurotoxic effects. It is also possible that longer DUP has psychosocial effects, which could mediate its impact on outcomes. The evidence of relevance to such socially toxic effects is reviewed, with particular reference to the possible role of social support. There is no definite evidence for social support as a mediator of the influence of DUP, but further investigation of this issue is warranted.

The Concept of Schizophrenia: From Unity to Diversity

After over 100 years of research without clarifying the aetiology of schizophrenia, a look at the current state of knowledge in epidemiology, genetics, precursors, psychopathology, and outcome seems worthwhile. The disease concept, created by Kraepelin and modified by Bleuler, has a varied history. Today, schizophrenia is considered a polygenic disorder with onset in early adulthood, characterized by irregular psychotic episodes and functional impairment, but incident cases occur at all ages with marked differences in symptoms and social outcome. Men’s and women’s lifetime risk is nearly the same. At young age, women fall ill a few years later and less severely than men, men more rarely and less severely later in life. The underlying protective effect of oestrogen is antagonized by genetic load. The illness course is heterogeneous and depressive mood the most frequent symptom. Depression and schizophrenia are functionally associated, and affective and nonaffective psychoses do not split neatly. Most social consequences occur at the prodromal stage. Neither schizophrenia as such nor its main symptom dimensions regularly show pronounced deterioration over time. Schizophrenia is neither a residual state of a neurodevelopmental disorder nor a progressing neurodegenerative process. It reflects multifactorial CNS instability, which leads to cognitive deficits and symptom exacerbations.

Family functioning in first-episode psychosis: a systematic review of the literature

PURPOSE

The influential role of family in the outcome of chronic schizophrenia is well documented. However, there has been relatively little research on the intrafamilial relationships of people experiencing their first episode of psychosis (FEP), a point in time when most of the changes in family dynamics are observed. The aim of this article is to present a review of the literature focusing on the family environment of FEP patients.

METHODS

We carried out a computerized literature search on MEDLINE and PsycINFO (1990-2013), and a manual search of references of pertinent articles. In total, 27 studies investigating expressed emotion (EE) and family burden (FB) in FEP were identified and fulfilled the inclusion criteria.

RESULTS

Similar to chronic patients, a high prevalence of high-EE in carers of FEP patients was reported. High-EE status appears to be independent of the patient's illness-related characteristics, but dependent of relatives' attributions. In contrast to chronic patients, low levels of FB and psychological distress among family members of FEP patients were observed indicating that in the early stages of the illness family involvement is not yet associated with significant disruption in their lives. Studies assessing FB in chronic patients have found a well-established link of FB with patient's illness-related factors, but in FEP patients the families' appraisal of FB is more closely associated with their coping mechanisms.

CONCLUSIONS

Further studies evaluating family functioning in terms of cohesion and adaptability will shed light on the intrafamilial relationships in FEP patients which may be associated with the long-term outcome of this chronic illness.