Burden of relatives and predictors of burden. Baseline results from the Munich 5-year-follow-up study on relatives of first hospitalized patients with schizophrenia or depression

Psychosocial burden in mothers with epilepsy and their caregiver: Feasibility and preliminary results of a digital screening procedure

OBJECTIVE

The present study aims to evaluate the feasibility of utilizing a digital procedure to screen for anxiety and depression as well as impairments in psychosocial aspects, such as social support, social activity and quality of life (QoL) in women with epilepsy (WWE) after childbirth. Furthermore, the study intends to digitally screen for burden of the respective caregivers in WWE compared to a healthy control group.

MATERIALS AND METHODS

This comparative cross-sectional study was conducted in the post-partum period on 30 WWE and 33 healthy controls who gave birth between 01/2018 and 05/2021. Additionally, 24 caregivers of WWE and 26 caregivers of healthy mothers took part in this study. Information on psychosocial health and psychosocial burden was collected digitally using the short version of the Social Support Questionnaire, the Social Activity Self-Report Scale and the Hospital Anxiety and Depression Scale. The caregiver burden was digitally assessed with the Zarit Burden Scale in its German adaptation (i.e., Zarit Burden Interview and the Family Burden Questionnaire). Furthermore, QoL was assessed with the QOLIE-31 (Quality of Life in Epilepsy Inventory) in WWE and with the Life Satisfaction Questionnaire in healthy controls.

RESULTS

When comparing WWE and healthy controls, the groups were comparable on psychosocial aspects, such as self-reported social support, anxiety, depression and social activity, when assessed with self-report measures in a digital screening procedure. Although not significantly different between groups, anxiety, depression, self-reported social support and social activity were correlated with overall QoL in both, WWE and healthy controls. Caregivers of WWE and healthy controls were neither significantly different in their objective burden nor in their subjective burden as reported in digitally applied self-report measures.

CONCLUSION

Although not significantly different between groups, given the correlation between psychosocial aspects and QoL, it is worthwhile to include these aspects in standard clinical screening extending beyond the screening of anxiety and depression in WWE. Overall, the preliminary psychosocial data presented in this study suggest that a digital assessment of psychosocial burden seems reasonable in WWE and warrants integration into further research and clinical practice. Nevertheless, since no significant differences concerning psychosocial aspects were found in the present study, one may argue that highly specialized clinical care, as provided in the present study, may counteract potential psychosocial impairment experienced by WWE who do not receive such specialized care. Hence, further investigations outside of specialized outpatient clinics as well as prospective investigations of subjective factors that may dynamically change during pregnancy ought to be addressed in clinical practice and research for improving care during and after pregnancy in WWE.

Informal caregivers of people with a diagnosis of schizophrenia: determinants and predictors of resilience

BACKGROUND

The extant literature portrays informal caregiving by family members who care for a person with a diagnosis of schizophrenia, as one that involves a tremendous amount of stress and burden.

AIM

This investigation sought to assess informal caregiving experience with regard to variables such as perceived positive aspects, preparedness, resilience, and life satisfaction.

METHOD

Data was collected from two groups of respondents accessing services at the Thanjavur Medical College Hospital, Tamil Nadu, India. The study group consisted of 75 family caregivers of persons with a diagnosis of schizophrenia and the reference group had an equal number of caregivers of people with minor physical ailments. The two groups were matched on important background factors, ensuring their comparability. Standardised instruments were administered to all respondents to collect data pertaining to the key variables and analysed using appropriate statistical procedures.

RESULTS

Results indicated that caregivers of people with a diagnosis of schizophrenia, while manifesting higher levels of resilience, perceived lesser positive aspects in their caring role. A significant statistical difference between both groups of respondents in terms of their life satisfaction and resilience. Regression analyses extracted preparedness and life satisfaction as significant contributors to the manifestation of resilience in the caregivers.

CONCLUSIONS

The study highlights the importance of caregiver preparedness and life satisfaction in enhancing their resilience.

A new way to measure partner burden in depression: Construction, validation, and sensitivity to change of the partner burden in depression questionnaire

Depression occurs in an interpersonal dynamic and living with a depressed person can lead to a significant burden on the partner. Instruments measuring burden do not address couples and often measure caregiving for individuals with schizophrenic disorders. The partner burden in depression (PBD) questionnaire is a new instrument measuring PBD by asking individuals, (1) which symptoms they can observe in their depressed partners and (2) to which degree this burdens them. Hence, PBD combines measuring the awareness of observed depressive symptoms and the resulting burden. Additionally, it addresses aspects unique to couple relationships. Our German validation confirmed a one-factor model with 12 items. The PBD had good psychometric properties and was sensitive to change. Partner burden predicted self-reported depressive symptoms (PHQ-9) over time. PBD is short, easily applicable in research and practice and can add to the understanding of partner effects in depression.

The impact of community care: Burden and quality of life of the informal caregivers of patients with severe mental disorder

This study analyzes the dimensions and consequences of the burden of caregivers of patients with SMD (Severe Mental Disorder) and the repercussions that this role has on their quality of life and health in the physical, psychic and social spheres. This is a descriptive cross-sectional study and inferential observational study which explores caregivers of patients with SMD admitted to Psychiatry Day Hospital (Huesca, Spain). The technique of consecutive cases was used as a technique for sampling and sample selection. An individualized interview was arranged, where sociodemographic data were collected and scales and instruments were administered. 52 caregivers met the inclusion criteria. The female sex predominates (67%), being the patient's mother (48%). The average age of caregivers is 60 years old. Almost 60% of the sample presents intense burden and alterations of general mental health, 77% reveal anxiety and depression, and 46% little social support. Burden is associated with hospitalization within the last year, anxiety, or total social support received. It is appreciated how the diagnosis of a chronic disease constitutes an important challenge for the patient and their family, due to the burden of the disease and the impact of the new routines imposed by the continuous treatment.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A web-based, peer-supported self-management intervention to reduce distress in relatives of people with psychosis or bipolar disorder: the REACT RCT

BACKGROUND

Relatives caring for people with severe mental health problems find information and emotional support hard to access. Online support for self-management offers a potential solution.

OBJECTIVE

The objective was to determine the clinical effectiveness and cost-effectiveness of an online supported self-management tool for relatives: the Relatives' Education And Coping Toolkit (REACT).

DESIGN AND SETTING

This was a primarily online (UK), single-blind, randomised controlled trial, comparing REACT plus a resource directory and treatment as usual with the resource directory and treatment as usual only, by measuring user distress and other well-being measures at baseline and at 12 and 24 weeks.

PARTICIPANTS

A total of 800 relatives of people with severe mental health problems across the UK took part; relatives who were aged ≥ 16 years, were experiencing high levels of distress, had access to the internet and were actively seeking help were recruited.

INTERVENTION

REACT comprised 12 psychoeducation modules, peer support through a group forum, confidential messaging and a comprehensive resource directory of national support. Trained relatives moderated the forum and responded to messages.

MAIN OUTCOME MEASURE

The main outcome was the level of participants' distress, as measured by the General Health Questionnaire-28 items.

RESULTS

Various online and offline strategies, including social media, directed potential participants to the website. Participants were randomised to one of two arms: REACT plus the resource directory (n = 399) or the resource directory only (n = 401). Retention at 24 weeks was 75% (REACT arm, n = 292; resource directory-only arm, n = 307). The mean scores for the General Health Questionnaire-28 items reduced substantially across both arms over 24 weeks, from 40.2 (standard deviation 14.3) to 30.5 (standard deviation 15.6), with no significant difference between arms (mean difference -1.39, 95% confidence interval -3.60 to 0.83; p = 0.22). At 12 weeks, the General Health Questionnaire-28 items scores were lower in the REACT arm than in the resource directory-only arm (-2.08, 95% confidence interval -4.14 to -0.03; p = 0.027), but this finding is likely to be of limited clinical significance. Accounting for missing data, which were associated with higher distress in the REACT arm (0.33, 95% confidence interval -0.27 to 0.93; p = 0.279), in a longitudinal model, there was no significant difference between arms over 24 weeks (-0.56, 95% confidence interval -2.34 to 1.22; p = 0.51). REACT cost £142.95 per participant to design and deliver (£62.27 for delivery only), compared with £0.84 for the resource directory only. A health economic analysis of NHS, health and Personal Social Services outcomes found that REACT has higher costs (£286.77), slightly better General Health Questionnaire-28 items scores (incremental General Health Questionnaire-28 items score adjusted for baseline, age and gender: -1.152, 95% confidence interval -3.370 to 1.065) and slightly lower quality-adjusted life-year gains than the resource directory only; none of these differences was statistically significant. The median time spent online was 50.8 minutes (interquartile range 12.4-172.1 minutes) for REACT, with no significant association with outcome. Participants reported finding REACT a safe, confidential environment (96%) and reported feeling supported by the forum (89%) and the REACT supporters (86%). No serious adverse events were reported.

LIMITATIONS

The sample comprised predominantly white British females, 25% of participants were lost to follow-up and dropout in the REACT arm was not random.

CONCLUSIONS

An online self-management support toolkit with a moderated group forum is acceptable to relatives and, compared with face-to-face programmes, offers inexpensive, safe delivery of National Institute for Health and Care Excellence-recommended support to engage relatives as peers in care delivery. However, currently, REACT plus the resource directory is no more effective at reducing relatives' distress than the resource directory only.

FUTURE WORK

Further research in improving the effectiveness of online carer support interventions is required.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN72019945.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 32. See the NIHR Journals Library website for further project information.

Carer subjective burden after first-episode psychosis: Types and predictors. A multilevel statistical approach

BACKGROUND

Carer burden at first-episode psychosis is common and adds to the multiple other psychiatric and psychological problems that beset new carers; yet, knowledge of the factors that predict carer burden is limited.

AIM

This study sought to investigate the types and predictors of carer burden at first-episode psychosis in the largest, most ethnically diverse and comprehensively characterised sample to date.

METHOD

This study involved a cross-sectional survey of carers of people with first-episode psychosis presenting to Harrow and Hillingdon Early Intervention in Psychosis service between 2011 and 2017. Carers completed self-report measures assessing their illness beliefs, coping styles and caregiving experiences (i.e. burden). Thirty carer and patient sociodemographic and clinical factors were also collected. Mixed effects linear regression modelling was conducted to account for clustering of carers by patient, with carer burden (and its 8 subtypes) investigated as dependent variables.

RESULTS

The sample included data on 254 carers (aged 18-74 years) and 198 patients (aged 14-36 years). Regression modelling identified 35 significant predictors of carer burden and its subtypes at first-episode psychosis. Higher total burden was independently predicted by perceiving greater negative consequences of the illness for the patient (B = .014, p < .001, 95% CI: [.010-.018]) and the carer (B = .008, p = .002, 95% CI: [.003-.013]), and engaging in avoidant-focussed coping (B = .010, p = .006, 95% CI: [.003-.016]). Lower burden was independently predicted by patients being in a relationship (B = -.075, p = .047, 95% CI: [-.149 to -.001]). Predictors of the eight burden subtypes (difficult behaviours, negative symptoms, stigma, problems with services, effects on family, dependency, loss and need to backup) are also included in the article.

CONCLUSION

Findings can be used to inform the identification of carers 'at-risk' of experiencing burden and highlight potential targets for theraputic intervention to lower carer buden.

Coping with caregiving stress among caregivers of patients with schizophrenia

This study aimed to evaluate the coping strategies, including religious coping, used by the caregivers of patients with schizophrenia to deal with caregiving stress. Caregivers of 100 patients with schizophrenia, currently in clinical remission, were evaluated on Ways of the coping questionnaire, Brief religious coping scale, and General Health Questionnaire (GHQ-12). More often use of adaptive coping mechanisms (such as seeking social support, accepting responsibility, planful problem solving, and positive reappraisa) was associated with a lower level of residual symptoms and better functioning of the patient, and lower level of psychological morbidity as per the GHQ-12 among the caregivers. A higher grade of negative symptoms, general psychopathology, and PANSS total score was associated with lower use of positive religious coping and higher use of negative religious coping in the caregivers. More severe psychological morbidity among the caregivers was associated with lower use of positive religious coping and higher use of negative religious coping. To conclude, this study depicts that caregivers of patients with schizophrenia use a mixture of adaptive and maladaptive coping strategies, including religious coping. The use of adaptive coping is associated with better patient-related outcomes and lower levels of psychological morbidity/distress among caregivers. Whereas, more frequent use of maladaptive coping is associated with both patients' and caregivers' outcomes.

Predictors of Expressed Emotion in First Episode Psychosis

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

An online supported self-management toolkit for relatives of people with psychosis or bipolar experiences: the IMPART multiple case study

Background

Digital health interventions have the potential to improve the delivery of psychoeducation to people with mental health problems and their relatives. Despite substantial investment in the development of digital health interventions, successful implementation into routine clinical practice is rare.

Objectives

Use the implementation of the Relatives’ Education And Coping Toolkit (REACT) for psychosis/bipolar disorder to identify critical factors affecting uptake and use, and develop an implementation plan to support the delivery of REACT.

Design

This was an implementation study using a mixed-methods, theory-driven, multiple case study approach. A study-specific implementation theory for REACT based on normalisation process theory was developed and tested, and iterations of an implementation plan to address the key factors affecting implementation were developed.

Setting

Early-intervention teams in six NHS mental health trusts in England (three in the north and three in the south).

Participants

In total, 281 staff accounts and 159 relatives’ accounts were created, 129 staff and 23 relatives took part in qualitative interviews about their experiences, and 132 relatives provided demographic data, 56 provided baseline data, 21 provided data at 12 weeks’ follow-up and 20 provided data at 24 weeks’ follow-up.

Interventions

REACT is an online supported self-management toolkit, offering 12 evidence-based psychoeducation modules and support via a forum, and a confidential direct messaging service for relatives of people with psychosis or bipolar disorder. The implementation intervention was developed with staff and iteratively adapted to address identified barriers. Adaptations included modifications to the toolkit and how it was delivered by teams.

Main outcome measures

The main outcome was factors affecting implementation of REACT, assessed primarily through in-depth interviews with staff and relatives. We also assessed quantitative measures of delivery (staff accounts and relatives’ invitations), use of REACT (relatives’ logins and time spent on the website) and the impact of REACT [relatives’ distress (General Health Questionnaire-28), and carer well-being and support (Carer Well-being and Support Scale questionnaire)].

Results

Staff and relatives were generally positive about the content of REACT, seeing it as a valuable resource that could help services improve support and meet clinical targets, but only within a comprehensive service that included face-to-face support, and with some additional content. Barriers to implementation included high staff caseloads and difficulties with prioritising supporting relatives; technical difficulties of using REACT; poor interoperability with trust information technology systems and care pathways; lack of access to mobile technology and information technology training; restricted forum populations leading to low levels of use; staff fears of managing risk, online trolling, or replacement by technology; and uncertainty around REACT’s long-term availability. There was no evidence that REACT would reduce staff time supporting relatives (which was already very low), and might increase it by facilitating communication. In all, 281 staff accounts were created, but only 57 staff sent relatives invitations. In total, 355 relatives’ invitations were sent to 310 unique relatives, leading to the creation of 159 relatives’ accounts. The mean number of logins for relatives was 3.78 (standard deviation 4.43), but with wide variation from 0 to 31 (median 2, interquartile range 1–8). The mean total time spent on the website was 40.6 minutes (standard deviation 54.54 minutes), with a range of 0–298 minutes (median 20.1 minutes, interquartile range 4.9–57.5 minutes). There was a pattern of declining mean scores for distress, social dysfunction, depression, anxiety and insomnia, and increases in relatives’ well-being and eHealth literacy, but no changes were statistically significant.

Conclusions

Digital health interventions, such as REACT, should be iteratively developed, evaluated, adapted and implemented, with staff and service user input, as part of a long-term strategy to develop integrated technology-enabled services. Implementation strategies must instil a sense of ownership for staff and ensure that they have adequate training, risk protocols and resources to deliver the technology. Cost-effectiveness and impact on workload and inequalities in accessing health care need further testing, along with the generalisability of our findings to other digital health interventions.

Limitations

REACT was offered by the same team running the IMPlementation of A Relatives’ Toolkit (IMPART) study, and was perceived by staff and relatives as a time-limited research study rather than ongoing clinical service, which affected engagement. Access to observational data was limited.

Trial registration

Current Controlled Trials ISRCTN16267685.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 37. See the NIHR Journals Library website for further project information.

Ensemble programme for early intervention in informal caregivers of psychiatric adult patients: a protocol for a randomised controlled trial

INTRODUCTION

Informal caregivers play a major role in the support and maintenance of community patients with severe psychiatric disorders. A pilot study showed that an individualised brief intervention such as the Ensemble programme leads to significant improvements in psychological health state and optimism.

METHODS AND ANALYSIS

This randomised controlled trial aims to compare the efficacy of using Ensemble in improving informal caregivers' psychological health states and the ability to play an active role in their situations with that of support as usual. Improvements on the psychological health global index will be measured three times (T0-pre, T1-post and T3 2 months follow) with standardised questionnaires (the Global Severity Index of Brief Inventory Symptoms, the Life Orientation Test-Revised, the 36-item Medical Outcome Study Short-Form Health Survey and the French Zarit Burden Interview). Differences between groups in post-test and pretest values will be examined using an analysis of covariance for each outcome variable. The severity of illness measured by the Social and Occupational Functioning Assessment Scale will also be collected at T0 and T2 to compare eventual patient improvements. At the end of the programme, the experiences of the 20 patients participating in the Ensemble programme will be evaluated qualitatively.

ETHICS AND DISSEMINATION

The research protocol received full authorisation from the Human Research Ethics Committee of the Vaud state, Switzerland. The principal paper will concern the results of the experimental design used to test the Ensemble programme. The research team will prioritise open access publications.

TRIAL REGISTRATION NUMBER

NCT04020497.

Clinical effectiveness of a web-based peer-supported self-management intervention for relatives of people with psychosis or bipolar (REACT): online, observer-blind, randomised controlled superiority trial

BACKGROUND

The Relatives Education And Coping Toolkit (REACT) is an online supported self-management toolkit for relatives of people with psychosis or bipolar designed to improve access to NICE recommended information and emotional support.

AIMS

Our aim was to determine clinical and cost-effectiveness of REACT including a Resource Directory (RD), versus RD-only.

METHODS

A primarily online, observer-blind randomised controlled trial comparing REACT (including RD) with RD only (registration ISRCTN72019945). Participants were UK relatives aged > = 16, with high distress (assessed using the GHQ-28), and actively help-seeking, individually randomised, and assessed online. Primary outcome was relatives' distress (GHQ-28) at 24 weeks. Secondary outcomes were wellbeing, support, costs and user feedback.

RESULTS

We recruited 800 relatives (REACT = 399; RD only = 401) with high distress at baseline (GHQ-28 REACT mean 40.3, SD 14.6; RD only mean 40.0, SD 14.0). Median time spent online on REACT was 50.8 min (IQR 12.4-172.1) versus 0.5 min (IQR 0-1.6) on RD only. Retention to primary follow-up (24 weeks) was 75% (REACT n = 292 (73.2%); RD-only n = 307 (76.6%)). Distress decreased in both groups by 24 weeks, with no significant difference between the two groups (- 1.39, 95% CI -3.60, 0.83, p = 0.22). Estimated cost of delivering REACT was £62.27 per person and users reported finding it safe, acceptable and convenient. There were no adverse events or reported side effects.

CONCLUSIONS

REACT is an inexpensive, acceptable, and safe way to deliver NICE-recommended support for relatives. However, for highly distressed relatives it is no more effective in reducing distress (GHQ-28) than a comprehensive online resource directory.

TRIAL REGISTRATION

ISRCTN72019945 prospectively registered 19/11/2015.

Longitudinal associations of family burden and patient quality of life in the context of first-episode schizophrenia in the RAISE-ETP study

The present study examined longitudinal associations between family member perceived burden and clinical correlates to understand potential covariation in change over time in the context of first-episode schizophrenia in the RAISE-ETP study (N = 282). Across 24 months, family burden, patient quality of life, and positive symptoms improved. Findings from the present study suggest covariation in change over time in quality of life and family burden. As patient quality of life improved, family burden decreased. However, initial levels of quality of life were not significantly associated with changes in family burden and vice versa. Initial levels of positive symptoms were significantly associated with initial levels of family burden. These findings have treatment implications by suggesting the potential for interventions aimed at improving quality of life to have a spillover effect on family burden, or alternatively, that reducing perceived family burden may improve patient quality of life.

Ecological Validity of Expressed Emotion in Early Psychosis

Expressed emotion (EE) is an aspect of the family environment that influences the course of multiple forms of psychopathology. However, there is limited research about how EE dimensions [i.e., criticism and emotional over-involvement (EOI)] are expressed in real-world settings. The present study used experience sampling methodology to investigate: 1) the criterion and construct validity of daily-life, momentary measures of criticism and EOI, and 2) the construct and ecological validity of psychometric EE-dimensions as assessed with the self-report Family Questionnaire (FQ). A total sample of 55 relatives (34 relatives of at-risk mental state patients and 21 of first-episode psychosis patients) were prompted randomly six times daily for 1-week to assess their current emotional experiences and cognitive appraisals. Relatives also completed the FQ. Momentary criticism and EOI were significantly associated with the two FQ-EE dimensions respectively, supporting the criterion validity of real-world assessed EE dimensions. As hypothesized, momentary and FQ-EE dimensions were associated with decreased positive affect, as well as with appraisals of less effective coping in daily life. Only momentary EE dimensions were associated with increased momentary negative affect. Partly in contrast with our hypotheses, momentary criticism and FQ-criticism were more consistently related to situational stress and burden than momentary EOI and FQ-EOI. Finally, neither momentary nor FQ-EE dimensions showed distinct patterns of associations with illness attributions. Findings partly support the construct validity of momentary criticism and EOI as well as the construct and ecological validity of the FQ as a sensitive measure of EE dimensions.

Optimism and the Psychological Recovery Process Among Informal Caregivers of Inpatients Suffering From Depressive Disorder: A Descriptive Exploratory Study

Background: Informal caregivers of people suffering from depressive disorders go through a psychological recovery process. This process is dynamic, deep, catalyzed by hope and optimism and characterized by stages from which specific needs ensue. This study aimed to describe the stages of the psychological recovery process and the level of optimism among informal caregivers of psychiatric inpatients suffering from depressive disorders in order to provide adapted nursing support and psychoeducation and facilitate a patient's own recovery. Methods: A descriptive exploratory study was conducted using a convenience sample of 29 informal caregivers. Participants filled out a sociodemographic questionnaire, a specially adapted Stages of Recovery Instrument (STORI) and the Life Orientation Test-Revised (LOT-R). Results: A mean optimism score of 16.41 showed that informal caregivers are close to the level of the general European population. The sample included all the stages of the recovery process, with 34.5% of participants being in the growth stage. Informal caregivers' stages in the recovery process were negatively associated with the patient's length of illness (Rho = -.683, p = .000) and positively associated with the caregivers' level of optimism (Rho = .564, p = .001). Conclusion: During the inpatient treatment of a close relative suffering from a depressive disorder, informal caregivers go through an individual psychological recovery process involving several stages. In addition to caring for inpatients, nurses are encouraged to meet and support caregivers as soon as possible in their individual recovery process. Furthermore, the development of a suitably adapted clinical tool would facilitate the assessment of the informal caregiver's stage in the recovery process within care units. A multidisciplinary approach is needed in this domain.

Caregiver distress in schizophrenia and mood disorders: the role of illness-related stressors and caregiver-related factors

BACKGROUND

Studies using the stress-appraisal-coping model to examine caregiving in schizophrenia and mood disorders are limited.

AIM

This study attempted to examine psychological distress among caregivers of persons with schizophrenia and mood disorders using the framework of the stress-coping theory. The impact of illness-related stressors and caregiver-related factors on caregiver-distress was also explored.

METHODS

In this cross-sectional study, 176 of the 238 selected outpatients with remitted schizophrenia, bipolar and recurrent depressive disorders identified over a 1-year period underwent standardized assessments of psychopathology and functioning. Assessments of burden, appraisal, coping, social support, neuroticism, familial-cultural variables and psychological distress (as an index of caregiving-outcome) were also carried out among family-caregivers of these persons.

RESULTS

High levels of caregiver-burden and caregiver-distress and a mix of positive and negative appraisal, adaptive and maladaptive coping, and high and low levels of perceived support among caregivers characterized the caregiving experience. Univariate analyses revealed that both illness-related stressors (symptom-severity, level of functioning, objective burden) and caregiver-related factors (subjective burden, appraisal, coping, perceived support, family-cohesion, neuroticism, time spent in caregiving) influenced caregiver-distress. However, multivariate analyses demonstrated that caregiver-related factors such neuroticism, perceived support, time spent in caregiving, subjective burden and negative appraisal had a much greater influence on caregiver-distress than illness-related stressors.

CONCLUSIONS

Although interactions between illness-related stressors and caregiver attributes appear to determine caregiver-distress, subjective perceptions and other attributes of caregivers may have a greater impact on distress. Therefore, interventions to reduce caregiver-distress should place equal, if not more emphasis on caregiver-related factors which influence distress.

A bittersweet relationship: What does it mean to be the caregiver of a patient with bipolar disorder?

BACKGROUND

As with most of the chronic illnesses, the changes and consequences brought on by bipolar disorder (BD) are not exclusive to the patient and often spread to those around them, especially for direct caregivers of these patients. It is known that there is a significant emotional and physical toll among persons who coexist daily with those who suffer from this disorder.

OBJECTIVE

Aware of the importance of the role played by informal caregivers (especially the family) in the stability and evolution of patients with bipolar disorder, this study seeks to explore the perception that family members responsible for bipolar persons have of themselves as caregivers of these patients.

METHOD

This is a qualitative study using a phenomenological design, for which the technique of focused or semi-structured interviews was employed. Ten caregivers of people with diagnosis of BD agreed to participate.

RESULTS

Within the family, it is a single individual who has the role of caregiver. Experiences and meanings that are generated into the nucleus of the patient-caregiver relationship are full of ambivalence and involve many aspects worthy of analysing, such as the development of identities, the feminization of patient care, the process of therapeutic decision-making and the evolution of the disease.

CONCLUSIONS

It is necessary to integrate evaluation and attention for patients' caregivers, recognizing them as individuals and elucidating their constructed meanings and the dynamics established in their relationship with patients. In this way, there would be a more integrative clinical approach of the patient-caregiver relationship, considering not only the necessary pharmacological treatments but also accompanying both patient and family, along the path they travel as they experience BD.

Feasibility and Accessibility of a Tailored Intervention for Informal Caregivers of People with Severe Psychiatric Disorders: a Pilot Study

OBJECTIVES

This study aimed to assess the acceptability and feasibility of a new tailored intervention for informal caregivers: the Ensemble (Together) program.

METHODS

An open pre-post within-subject comparison pilot study was conducted. Twenty-one informal caregivers completed the five-session Ensemble program. Two measurement tools were used: The Brief Symptom Inventory (BSI) and the Life Orientation Scale (LOT-R).

RESULTS

The results showed that informal caregivers were in need of individual support and were ready to participate in the Ensemble program independent of the patient's diagnosis or stage of illness. The participants were very satisfied, and 95.4% completed the program. The preliminary results also showed that in five sessions, informal caregivers' Global Severity Index measured by the BSI and their optimism about their future (measured by the LOT-R) were significantly improved.

CONCLUSION

This pilot study provided preliminary results concerning the feasibility and acceptability of the tailored Ensemble program and indicates the need for a randomized trial. The Ensemble program is appropriate for both the acute and chronic phases of disease. Individualized brief and useful interventions for informal caregivers may provide more positive outcomes in care.

Effect of caregivers' expressed emotion on the care burden and rehospitalization rate of schizophrenia

BACKGROUND

This study assessed the effect of expressed emotion (EE) among caregivers of schizophrenia patients on their care burden and the illness rehospitalization rate.

SUBJECTS AND METHODS

A total of 64 schizophrenia patients hospitalized for the first time and their key caregivers were recruited. The Chinese version of the Camberwell Family Interview (CFI-CV) was used to evaluate the EE of the key caregivers. A family burden questionnaire was used to evaluate the care burden. The patients' rehospitalization rate and medication compliance were evaluated by the self-designated criteria. The data collection was carried out at the first meeting in the hospital, at 6 months and 12 months after hospital discharge by using the same instruments.

RESULTS

The subjective stress burden and subjective demand burden scores were higher in caregivers before and after discharge with statistical difference between the various observation time points (P<0.05). Significant differences were observed in the rehospitalization rate between patients with high medication adherence and low medication adherence at 12 months (P<0.01) and between patients with high expressed emotion (HEE) and low expressed emotion (LEE; P<0.05). The rehospitalization rate in patients with HEE caregivers was higher than that in those with LEE caregivers. The subjective stress burden scores were statistically significant between HEE and LEE caregivers (P<0.05).

CONCLUSION

HEE is a predictor of rehospitalization rate in schizophrenic patients. The burdens of care scores are high in caregivers of schizophrenic patients. The caregivers with HEE have a high score in burden of care compared with those with LEE.

Perceptions of schizophrenia and coping styles in caregivers: comparison between India and Switzerland

WHAT IS KNOWN ON THE SUBJECT?: Negative perceptions of illnesses can increase caregivers' use of ineffective coping strategies, which may increase their burdens and distress. Scientific and theoretical framework showed that culture and health organization system influence perception of illnesses and thus also has an impact on the coping strategies used. There is a lack of data on comparative perceptions of illnesses and coping styles between India and Switzerland and that is why this hypothesis needs to be confirmed. The comparison between two countries with large cultural and socioeconomics differences will provide a more significant impact. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This cultural comparative study explores the associations between representations of illness and three forms of coping styles (i.e. problem-focused, emotion-focused and social support-focused coping) among caregivers of people diagnosed with schizophrenia spectrum disorders in Mangalore, India, and in French-speaking Switzerland. Results showed significant differences between Swiss and Indian caregivers practically in all illness' perceptions and coping styles, which is in accord with the theoretical framework. However, two results showed also similarities: the perception that schizophrenia can have cyclical episodes and that it can have negative consequences for caregivers. These differences and similarities allow to confirm the hypothesis that culture and health organization system influence illness' perception which impact the used coping styles. However, to develop specific nursing interventions for each culture, more research is needed to specify qualitatively the content of these differences and similarities. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Knowledge of how culture influences perceptions and coping styles is essential to develop quality interventions. Nurses should evaluate caregivers' perceptions and the causes they attribute to illnesses to help them maintain or develop efficient coping strategies. Knowledge of specific cultural differences and similarities can help nurses to provide individualized care that takes into account personal values to ensure recovery processes.

ABSTRACT

Introduction Scientific and theoretical framework showed that culture and health organization system influence perception of illnesses and thus also has an impact on the coping strategies used. Aim/question This cultural comparative study explores illness' perception and coping styles among the caregivers of people diagnosed with schizophrenia spectrum disorders in Mangalore, India, and Lausanne, Switzerland. Method The answers of 92 Swiss caregivers, using paper or electronic surveys depending on the participants' preference, and 100 Indian caregivers via an interview with a nurse were examined. Results The results confirm the hypothesis that culture and health organization system influence illness' perception which impact the used coping styles. Significant differences between Swiss and Indian caregivers practically in all illness' perceptions and coping styles were present, which is in accord with the theoretical framework. However, two results showed also similarities: the perception that schizophrenia can have cyclical episodes and that it can have negative consequences for caregivers. Discussion These differences will affect the development of interventions for caregivers in both countries. Implications for Practice The cultural differences observed in this study not only will allow interventions to be adapted to the specific needs of the two populations but also to identify their shared needs.

Family Functioning in First-Episode and Chronic Psychosis: The Role of Patient's Symptom Severity and Psychosocial Functioning

The aim of the present study was to assess the relationship between illness-related characteristics, such as symptom severity and psychosocial functioning, and specific aspects of family functioning both in patients experiencing their first episode of psychosis (FEP) and chronically ill patients. A total of 50 FEP and 50 chronic patients diagnosed with schizophrenia or bipolar disorder (most recent episode manic severe with psychotic features) and their family caregivers participated in the study. Family functioning was evaluated in terms of cohesion and flexibility (FACES IV Package), expressed emotion (FQ), family burden (FBS) and caregivers' psychological distress (GHQ-28). Patients' symptom severity (BPRS) and psychosocial functioning (GAS) were assessed by their treating psychiatrist within 2 weeks from the caregivers' assessment. Increased symptom severity was associated with greater dysfunction in terms of family cohesion and flexibility (β coefficient -0.13; 95 % CI -0.23, -0.03), increased caregivers' EE levels on the form of emotional overinvolvement (β coefficient 1.03; 95 % CI 0.02, 2.03), and psychological distress (β coefficient 3.37; 95 % CI 1.29, 5.45). Family burden was found to be significantly related to both symptom severity (β coefficient 3.01; 95 % CI 1.50, 4.51) and patient's functioning (β coefficient -2.04; 95 % CI -3.55, -0.53). No significant interaction effect of chronicity was observed in the afore-mentioned associations. These findings indicate that severe psychopathology and patient's low psychosocial functioning are associated with poor family functioning. It appears that the effect for family function is significant from the early stages of the illness. Thus, early psychoeducational interventions should focus on patients with severe symptomatology and impaired functioning and their families.

Burden and Expressed Emotion of Caregivers in Cases of Adult Substance Use Disorder with and Without Attention Deficit/Hyperactivity Disorder or Autism Spectrum Disorder

OBJECTIVE

To identify and compare caregiver burden and expressed emotion (EE) in adult substance use disorder (SUD) patients with and without co-occurring attention deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD). To examine possible differences in correlations between caregiver burden and EE across patient groups.

DESIGN AND METHODS

Cross-sectional study with measures of perceived burden (Involvement Evaluation Questionnaire: IEQ), subjective stress (General Health Questionnaire: GHQ) and perceptions of expressed emotion (Level of Expressed Emotion: LEE) in informal caregivers for patients with SUD, SUD+ADHD or SUD+ASD.

FINDINGS

No differences in caregiver burden or expressed emotion when caregivers for patients with SUD were compared to caregivers for patients with SUD+ADHD. A moderate but non-significant difference for caregivers of patients with SUD versus SUD+ASD, which disappeared when the number of contact hours between patient and caregiver for the SUD only group was controlled for. The IEQ sum scores also substantially correlated with the LEE sum scores.

CONCLUSION

Informal caregivers for patients with only SUD show higher levels of burden and EE than informal caregivers for patients with SUD and a co-occurring ASD. This difference was largely explained by the higher number of contact hours between patient and caregiver in the SUD only group.

Impact of patients' psychiatric hospitalization on caregivers: a systematic review

OBJECTIVE

A systematic literature review was conducted to assess the impact of patients' psychiatric hospitalizations on caregivers.

METHODS

A systematic search of the Web of Knowledge, PsycINFO, and MEDLINE (PubMed) was conducted for peer-reviewed articles published in English before August 31, 2013. Qualitative, quantitative, and mixed-methods studies were included if they focused on the outcomes of caregivers of either adult or youth patients and presented data collected directly from caregivers of patients who had been psychiatrically hospitalized.

RESULTS

Twenty-nine articles met the inclusion criteria. The review found that caregivers are heterogeneous in their reaction to patients' psychiatric hospitalization; however, many report distress. Many caregivers have reported experiencing stigma, disruptions in daily life, worse general medical health, economic strain, and changes in relationships after hospitalization. Negative reactions to the hospitalization may decrease over time, but distress can remain elevated compared with the general population. Nonetheless, many caregivers have also reported experiencing positive changes as a result of the hospitalization. The reaction of caregivers may be influenced by the severity of the patient's psychiatric problems as well as the caregiver's demographic characteristics and style of coping.

CONCLUSIONS

Caregivers experience a range of reactions to psychiatric hospitalizations. Providing caregivers with psychoeducation about their possible reaction to hospitalization and teaching them coping techniques may improve clinical outcomes for patients. Future research is needed to understand the heterogeneity in caregivers' reactions to patients' psychiatric hospitalization.

Burden, reward, and coping of adult offspring of patients with depression and bipolar disorder

Background

In previous years, research has focused on the situation of psychiatric patients' minor children. The aims of this qualitative study were to describe the experience of adult children of depressed and bipolar patients, including positive and negative factors as well as coping mechanisms, and to investigate possible predictors of burden in order to identify children in need of professional support.

Methods

A total of 30 adult children were interviewed using a semi-structured interview. In addition, all children completed the Freiburg Questionnaire of Coping with Disease (Freiburger Fragebogen zur Krankheitsverarbeitung, FKV). Regression analysis indicated the most relevant predictors of burden.

Results

All (100%) of the children reported emotional burden due to the illness of their parent, 90% suffered from impaired family life, and 77% experienced burden due to the parent's symptoms. Reward (positive experience) was reported regarding the intensification of the parent-child relationship. Linear regression analysis shows predictors for highly burdened children as well as for children who are more prone to maladaptive ways of coping. Higher burden was significantly associated with the child's age, severity of illness of the parent, and specific diagnosis.

Conclusions

Although some positive aspects of parental affective disorder exist, this study underlines that children primarily suffer from their parent's disorder and that this burden does not stop in adulthood. Providing professional support to adult as well as to minor children of affected individuals should become standard of care in clinical settings.

Coping among the caregivers of patients with schizophrenia

Coping is understood as the process of managing external or internal demands that are considered as taxing or exceeding the resources of the person. There is no formal classification of coping strategies, and these are understood as adaptive versus maladaptive and problem focuses versus emotion-focused. Understanding the commonly used coping strategies in a particular group of subjects can provide valuable insights for designing interventions to reduce the stress. In this review, we look at the literature which is available with regards to the coping strategies used by the caregivers of patients with schizophrenia. Findings suggest that caregivers of patients with schizophrenia use mixed type of coping mechanisms to deal with the stress of caregiving. The coping strategies are shown to have association with variables such as caregiver burden, caregiving experience, expressed emotions, social support, psychological morbidity in the caregivers, quality of life of caregivers and psychopathology in patients. One of the major limitations of the literature is that there is a lot of variability in the assessment instruments used across different studies to assess coping.

Predictors of depression among caregivers of older adults with severe mental illness

Caregivers of older persons with severe mental illness (SMI) contend with the double challenge of providing assistance related to both the psychiatric condition and older age of their family member. Study explored factors influencing negative psychological outcomes experienced by caregivers (n = 96) of older adults with SMI. One-quarter of caregivers scored at or above the clinical point for depression. Low income, care recipient gender, poor health, problems dealing with care recipient's symptoms and the interaction of health and problems dealing with symptoms were associated with higher rates of depression. Implications for service provision and future research are discussed.

Towards a better understanding of caregiver distress in early psychosis: a systematic review of the psychological factors involved

OBJECTIVES

We sought to review empirical studies of psychological factors accounting for distress in caregivers of young people with early psychosis.

METHOD

Following the PRISMA guidelines, we included studies that empirically tested psychological models of caregiver distress in early psychosis by searching the following databases up until March 2014: PsycINFO, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL). This was followed by additional manual searches of reference lists and relevant journals.

RESULTS

The search identified 15 papers describing 13 studies together comprising 1056 caregivers of persons with early psychosis. The mean age of caregivers was 47.2years (SD=9.8), of whom 71.5% were female and 74.4% were parents. Nine different psychological variables were examined in the included studies, which were categorised in the following non-mutually exclusive groups: coping, appraisal/attribution and interpersonal response. There was considerable data to support the link between distress and psychological factors such as avoidant coping, appraisal and emotional over-involvement. However, the possibilities of drawing conclusions were limited by a number of methodological issues, including cross-sectional data, small sample sizes, confounding variables not being accounted for, and a wide variation in outcome measures.

DISCUSSION

The strengths of the review were the systematic approach, the exclusion of non-empirical papers and the rating of methodological quality by two independent raters. Limitations were that we excluded studies published in languages other than English, that data extraction forms were developed for this study and hence not tested for validity, and that there was a potential publication bias in favour of significant findings.

CONCLUSION AND IMPLICATIONS

A better grasp of the psychological factors accounting for caregiver distress early in the course of illness may help us understand the trajectory of distress. This is an important step in preventing long-term distress in caregivers and supporting recovery in the whole family.

Caregiver burden in families of patients with depression attending Obafemi Awolowo University teaching hospitals complex Ile-Ife Nigeria

OBJECTIVE

The objective of this study was to assess caregiver burden among relatives of patients on treatment for depressive disorder attending the psychiatry outpatient clinic of the Obafemi Awolowo University Teaching Hospitals Complex, Ile Ife, Nigeria.

METHODS

A cross sectional design was used. Hundred caregivers of patients with ICD-10 diagnosis of depression, on outpatient treatment for at least six months were recruited from the psychiatric outpatient clinic. Caregivers completed a semi-structured socio-demographic questionnaire, the Zarit Burden Interview and General Health Questionnaire (GHQ) 12. Descriptive statistics were used to describe socio-demographic variables; association between dependent and independent variables were assessed using Pearson's correlation, chi squared and t test as appropriate.

RESULTS

The mean ZBI score was 41.32 (S.D. = 9.82), 45% of respondents reported moderate to severe burden, spouses constituted 57% of caregivers. Age at onset of depression (t = 2.46, P = .02) number of hospitalization,(χ(2) = 9.82, P = 0.001), and current active symptoms (χ(2) = 36.1, P = .001) were all significantly associated with burden score. Severity of symptoms (r = 0.48, P < .01) and age at onset of illness (r = -0.26, P < .01) both correlated significantly with burden scores, while GHQ score among caregivers also correlated significantly with burden scores (r = 0.52, P < .01).

CONCLUSIONS

Caregivers of depressed patients experience moderate to severe burden. Caring for the depressed need to change from a patient focused approach to a combined patient and caregiver approach.

Cognitive insight in schizophrenia patients and their biological parents: a pilot study

BACKGROUND

Clinical insight in schizophrenia patients is partly associated with familial environment but has been poorly studied to date. We aimed to explore (1) the relationship between parents' cognitive insight and their offspring's; (2) the relationship between parents' cognitive insight and their clinical insight into the disease of their offspring; and (3) the clinical and cognitive determinants of cognitive insight in parents.

METHODS

Cognitive insight was assessed in 37 patient-biological parent pairs/dyads with the Beck Cognitive Insight Scale (BCIS). Other measures included the Scale to assess Unawareness of Mental Disorder and cognitive assessments.

RESULTS

We found no significant association between parents' cognitive insight and their offspring's. Conversely, a positive association between parents' cognitive insight and parents' insight into their offspring's symptoms was found. Better awareness of their offspring's specific symptoms was associated with lower levels of overconfidence in one's beliefs and with BCIS total score. BCIS Self-Certainty and BCIS total score were associated with better executive functioning and verbal comprehension.

CONCLUSIONS

Better insight into their offspring's symptoms is associated with cognitive insight in biological parents of schizophrenia patients. Our results support the integration of cognitive intervention targeting parents' cognitive flexibility in family psychoeducational programs and provide an important first step towards developing a more refined understanding of the factors involved in insight into symptoms of illness in parents of schizophrenia patients.

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.

Sobrecarga de familiares cuidadores em relação ao diagnóstico de pacientes psiquiátricos

Objetivo Comparar os graus das sobrecargas objetiva e subjetiva sentidas por familiares cuidadores de pacientes com esquizofrenia e por familiares cuidadores de pacientes com depressão maior, bem como os fatores associados e as dimensões mais afetadas em cada grupo. Métodos Participaram desta pesquisa 50 cuidadores de pacientes com esquizofrenia e 50 cuidadores de pacientes com depressão maior. Esses familiares participaram de uma entrevista estruturada, na qual foram aplicados dois instrumentos: a escala de sobrecarga FBIS-BR e um questionário. Resultados Os resultados indicaram que os dois grupos apresentavam diferenças significativas quanto ao grau de sobrecarga, na análise detalhada dos itens da escala. Os familiares cuidadores de pacientes com esquizofrenia apresentaram sobrecarga objetiva significativamente mais elevada ao assistir o paciente na tomada de medicamentos e na administração do dinheiro e apresentaram maior sentimento de peso financeiro resultante do papel de cuidador. Os cuidadores de pacientes com depressão maior apresentaram maior frequência de supervisão de comportamentos autoagressivos, mais preocupação com a vida social dos pacientes e maior sentimento de incômodo nas tarefas de assistência na vida cotidiana. Não foram encontrados dados significativos referentes aos escores globais da escala de sobrecarga. Conclusão As diferenças encontradas nesta pesquisa apontam para a necessidade de os serviços de saúde mental planejarem intervenções específicas para cada grupo de cuidadores.

Provision of group psychoeducation for relatives of persons in inpatient depression treatment--a cross-sectional survey of acute care hospitals in Germany

BACKGROUND

Depressive disorders are often recurrent and place a high burden on patients and their relatives. Psychoeducational groups for relatives may reduce relatives' burden, help prevent relapses in patients, and are recommended by the German "National Disease Management Guideline Unipolar Depression". Since there is limited knowledge on the provision of psychoeducational groups for relatives of persons in inpatient depression treatment, we conducted a survey among acute care hospitals in Germany.

METHODS

We conducted a two-step cross-sectional survey. Step I consisted of a questionnaire asking the heads of all psychiatric/psychosomatic acute care hospitals in Germany (N = 512) whether psychoeducational groups for relatives were provided within depression treatment, and if not, the reasons for not implementing them. In group offering hospitals the person responsible for conducting psychoeducational groups received a detailed questionnaire on intervention characteristics (step II). We performed descriptive data analysis.

RESULTS

The response rate was 50.2% (N = 257) in step I and 58.4% in step II (N = 45). 35.4% of the responding hospitals offered psychoeducational groups for relatives of patients with depressive disorders. According to the estimates of the respondents, relatives of about one in five patients took part in psychoeducational groups in 2011. Groups were mostly provided by two moderators (62.2%) as continuous groups (77.8%), without patients' participation (77.8%), with up to ten participants (65.9%), consisting of four or fewer sessions (51.5%) which lasted between one and one and a half hours each (77.8%). The moderators in charge were mostly psychologists (43.9%) or physicians (26.8%). Approximately one third used published manuals. Reasons for not conducting such psychoeducational groups were lack of manpower (60.1%), time (44.9%) and financial constraints (24.1%). 25.3% mentioned adequate concepts of intervention as a required condition for initiating such groups.

CONCLUSIONS

Only a small proportion of relatives of patients with depressive disorders participated in psychoeducational groups in 2011 in Germany. Mostly short interventions were favoured and main implementation barriers were scarce resources. Brief interventions that fit with healthcare routine should be developed and tested within randomised controlled trials. This could promote the provision of psychoeducational groups for relatives as evidence-based practice in inpatient depression treatment in Germany.

Predictors of expressed emotion, burden and quality of life in relatives of Mexican patients with psychosis

Expressed emotion, burden and quality of life of relatives received attention because of the increasing interest in predicting and preventing relapse in psychotic patients; but they have subsequently acquired interest of their own as important aspects of families' psychological well-being. The study explores whether the psychological distress and illness perception of a sample of relatives of Mexican patients with psychosis can predict their levels of expressed emotion, burden and quality of life above patients' clinical and functional status. Sixty-five patient-relative dyads were interviewed. Relatives self-reported on expressed emotion, burden, quality of life, psychological distress and illness perception. Patients' clinical and functional status was rated by an interviewer. Pearson correlations and hierarchical multiple linear regressions were used for statistical analyses. Patients' functional status and relatives' psychological distress were significantly associated with expressed emotion, burden and quality of life. Patients' clinical status and relatives' illness perception were most strongly related to expressed emotion and burden. Relatives' psychological distress and illness perception dimensions predicted both burden and quality of life, over and above patients' clinical and functional status. Results underscore the relatives' need of support to overcome their own distress and concerns about the illness, for the psychological well-being of both patients and relatives.

Mobile phone text message reminders of antipsychotic medication: is it time and who should receive them? A cross-sectional trust-wide survey of psychiatric inpatients

BACKGROUND

Poor adherence to antipsychotic medication is a widespread problem, and the largest predictor of relapse in patients with psychosis. Electronic reminders are increasingly used to improve medication adherence for a variety of medical conditions, but have received little attention in the context of psychotic disorders. We aimed to explore the feasibility and acceptability of including short message service (SMS) medication reminders in the aftercare plan of service users discharged from inpatient care on maintenance antipsychotic medication.

METHODS

We conducted a cross-sectional, trust-wide survey in the inpatient units of the Oxleas National Health Service (NHS) Foundation Trust in the UK between June 29 and August 3, 2012. Using a self-report questionnaire and the Drug Attitude Inventory, we examined inpatient attitudes towards antipsychotic drugs, past adherence to antipsychotic medication, frequency of mobile phone ownership, and interest in receiving SMS medication reminders upon discharge from the ward. Predictors of a patient's interest in receiving electronic reminders were examined using simple logistic regression models.

RESULTS

Of 273 inpatients, 85 met eligibility criteria for the survey, showed decisional capacity, and agreed to participate. Of the 85 respondents, over a third (31-35%) admitted to have forgotten to take/collect their antipsychotic medication in the past, and approximately half (49%) to have intentionally skipped their antipsychotics or taken a smaller dose than prescribed. Male patients (55%), those with negative attitudes towards antipsychotics (40%), and those unsatisfied with the information they received on medication (35%) were approximately 3 to 4 times more likely to report past intentional poor adherence. The large majority of respondents (80-82%) reported having a mobile phone and knowing how to use SMS, and a smaller majority (59%) expressed an interest in receiving SMS medication reminders after discharge. No variable predicted a patient's interest in receiving electronic reminders of antipsychotics.

CONCLUSIONS

Automatic SMS reminders of antipsychotic medication were acceptable to the majority of the survey respondents as an optional service offered upon discharge from inpatient care. Automatic electronic reminders deserve further investigation as a flexible, minimally invasive, cost-effective and broadly applicable tool that can potentially improve antipsychotic adherence and clinical outcomes.

Correlational study: illness representations and coping styles in caregivers for individuals with schizophrenia

BACKGROUND

Caring for individuals with schizophrenia can create distress for caregivers which can, in turn, have a harmful impact on patient progress. There could be a better understanding of the connections between caregivers' representations of schizophrenia and coping styles. This study aims at exploring those connections.

METHODS

This correlational descriptive study was conducted with 92 caregivers of individuals suffering from schizophrenia. The participants completed three questionnaires translated and validated in French: (a) a socio-demographic questionnaire, (b) the Illness Perception Questionnaire for Schizophrenia and (c) the Family Coping Questionnaire.

RESULTS

Our results show that illness representations are slightly correlated with coping styles. More specifically, emotional representations are correlated to an emotion-focused coping style centred on coercion, avoidance and resignation.

CONCLUSION

Our results are coherent with the Commonsense Model of Self-Regulation of Health and Illness and should enable to develop new interventions for caregivers.

Parents of young people with self-harm or suicidal behaviour who seek help - a psychosocial profile

BACKGROUND

Deliberate Self-Harm (DSH) is a common problem among children and adolescents in clinical and community populations, and there is a considerable amount of literature investigating factors associated with DSH risk and the effects of DSH on the child. However, there is a dearth of research examining the impact of DSH on parents, and there are few support programmes targeted at this population. This cross-sectional study examines the profile of a sample of parents of young people with DSH who participated in a support programme (Supporting Parents and Carers of young people with self-harm: the SPACE programme), with the goal of investigating pre-test parental well-being, family communication, parental satisfaction, perceived parental social support, and child strengths and difficulties.

METHODS

Participants were 130 parents who attended the SPACE programme between 2009 and 2012, and who completed six questionnaires at baseline: the General Health Questionnaire-12, Strengths and Difficulties Questionnaire, Kansas Parenting Satisfaction Scale, General Functioning Scale of the McMaster Family Assessment Device, Multidimensional Scale of Perceived Social Support, and a demographic questionnaire.

RESULTS

The majority of parents met criteria for minor psychological distress (86%) and rated the quantity and severity of their children's difficulties as being in the abnormally high range (74%) at baseline. A majority of participants (61%) rated their perceived social support as being poor. Lower parental well-being was significantly correlated with poorer family communication, poorer parenting satisfaction, and a greater number of difficulties for the child. Perceived social support was not significantly correlated with parental well-being. Parents whose children were not attending school at baseline had significantly lower well-being scores than those whose children were. Parents whose children had received a formal diagnosis of a mental health disorder also had significantly lower well-being scores than those whose children had not.

CONCLUSIONS

Parents of young people with DSH behaviours face considerable emotional and practical challenges; they have low levels of well-being, parenting satisfaction, social support, and experience poor family communication. Given the importance of parental support for young people with DSH behaviours, consideration should be given to the need for individual or group support for such parents.

Sources of parental burden in a UK sample of first-generation North Indian Punjabi Sikhs and their white British counterparts

OBJECTIVE

The correlates of parental burden in schizophrenia may differ between ethnic groups, but few studies have examined this in a UK setting. Our aim was to identify the correlates of burden in a UK sample of first-generation North Indian Punjabi Sikh parents and their white British counterparts.

METHOD

Test the association of burden with a series of clinical, social and service use variables and control for potential confounding factors in a model predicting drivers of burden in a combined sample of the above.

RESULTS

The strongest correlates of burden were patient symptoms and parental distress. Differences in correlates of burden between the groups emerged when individual components of service use and parental social network were tested. The group comparisons also revealed differences in expressed emotion (EE) and social networks.

CONCLUSION

The similarities in sources of burden between the groups could be explained by a commonality of sociocultural and economic experience, resulting from the successful acculturation and affluence of this British Sikh group. The differences between the groups may be related to enduring cultural factors such as kin support, since larger family groups were associated with low burden in the British Sikh group. The nature of EE in this British Sikh group may explain why it was not associated with burden in this sample.

Satisfaction with Life Scale (SWLS) in caregivers of clinically-referred youth: psychometric properties and mediation analysis

This paper presents the psychometric evaluation of the Satisfaction with Life Scale (SWLS; Diener et al. in J Personal Assess 49:71-75, 1985) used with a large sample (N = 610) of caregivers for youth receiving mental health services. Methods from classical test theory, factor analysis, and item response theory were utilized. Additionally, this paper investigated whether caregiver strain mediates the effect of youth symptom severity on caregiver life satisfaction (N = 356). Bootstrapped confidence intervals were used to determine the significance of the mediated effects. Results indicated that the SWLS is a psychometrically sound instrument to be used with caregivers of clinically-referred youth. Mediation analyses found that the effect of youth symptom severity on caregiver life satisfaction was mediated by caregiver strain but that the mediation effect differed based on the type of youth symptoms: caregiver strain was a partial mediator when externalizing symptoms were measured and a full mediator when internalizing symptoms were measured. Implications for future research and clinical practice are discussed.

Caregiver life satisfaction: relationship to youth symptom severity through treatment

This study utilized the Satisfaction with Life Scale to investigate the life satisfaction of caregivers for youth receiving mental health services (N = 383). Specifically, this study assessed how caregiver life satisfaction relates to youth symptom severity throughout treatment. Hierarchical linear modeling with a time-varying covariate was used to estimate the linear trajectory of caregiver life satisfaction and how it relates to youth symptom severity as rated by caregivers, youth, and clinicians. Results found initial caregiver life satisfaction was inversely related to caregiver and clinician rated youth symptom severity. In addition, subsequent caregiver life satisfaction demonstrated a small but significant relationship to changes in youth symptom severity during treatment where a decrease in youth symptoms corresponded to an increase in caregiver life satisfaction, and vice versa. Caregiver background characteristics related to higher life satisfaction included being (a) married, a birth parent, and younger than 40 years old, and (b) having the absence of previous diagnoses of an emotional, behavioral, or substance use disorder. Despite significant change over time, caregivers of clinically referred youth demonstrated low levels of life satisfaction throughout youth treatment. Given the bidirectional influences on one another, tending to the well-being of caregivers may positively influence both caregivers and youths.

Caregiver burden in chronic mental illness: the role of patient and caregiver characteristics

The aim of the present study is to identify the relative contribution of patient and caregiver characteristics in a sample of primary carers of patients with chronic mental disorders living in the community. As carers were recruited from caregiver organizations, mainly mothers of an adult child suffering from schizophrenia participated in the study (n = 102). Within a comprehensive transactional stress model, burden was assessed with respect to objective and subjective burden, cognitive-emotional well-being, psychological distress and subjective quality of life. Primary stressors include illness-related characteristics of the patient, and a number of personal dispositions and resources of the caregivers were included as potential moderating variables. Multiple regression analyses were separately calculated for each dimension of burden. Interaction of carers' expressed emotion and external locus of control with the patient's problem with family communication as well as perceived social support was most predictive for objective and subjective burden, whereas carers' neuroticism appeared as the most relevant predictor of their well-being, psychological distress and subjective quality of life. Among the patients' variables, regular employment contributed significantly to reduce carers' distress and enhance their well-being. As the sample was recruited from caregiver organizations, a selection bias has to be taken into account. To reduce caregiver burden, especially mothers' burden, the patients' occupational abilities should be strongly enhanced at an early stage. Family interventions should improve dysfunctional interactions, enhance the carers' social activities and focus more intensely on the carers' own dispositions.

Expressed and perceived emotion over time: does the patients' view matter for the caregivers' burden?

While the impact of mentally ill patients' perceptions of their key relatives' expressed emotion is well examined with regard to relapse, there is a paucity of evidence concerning the impact on their key relatives' burden. The present study aims to evaluate the relative prognostic value of expressed and perceived emotion on caregivers' stress outcome within a 3-year follow-up period. Yearly follow-up data of the key relatives of 16 first-hospitalized schizophrenic and 34 depressed patients were available including expressed and perceived emotion and different dimensions of caregivers' stress outcome: objective and subjective burden, well-being, psychological symptoms and subjective quality of life. Multiple linear regression analyses were computed to assess the relative impact of expressed and perceived emotion. All dimensions of burden were significantly and consistently correlated with caregivers' expressed emotion and patients' perceived criticism on the bivariate level. On the multivariate level, however, expressed criticism appeared to be the most relevant predictor, followed by perceived resignation. Data indicate that the impact of the patients' perceived criticism on caregivers' stress outcome is limited. More attention should be paid to patients' perceived resignation which may be an unidentified stress contributor for caregivers so far.

Mental disorder in Polish families: is diagnosis a predictor of caregiver's burden?

OBJECTIVE

To test whether a caregiver's burden is associated with the patient's psychiatric diagnosis and to find other predictors of family burden; to provide Polish data on the issue to international literature.

METHOD

Of 377 eligible subjects, 141 were interviewed on admission to the mental hospital using Brief Psychiatric Rating Scale, Manchester Short Assessment of Quality of Life, Groningen Social Disability Schedule and Client's Sociodemographic and Clinical History Inventory. Their caregivers completed the Involvement Evaluation Questionnaire (IEQ). Subjects were grouped according to ICD-10 diagnoses: schizophrenia (n = 55), depression (n = 61), and anxiety and personality disorders (n = 25). Highly aggressive, suicidal and somatically unstable patients were excluded along with patients below 18 and over 65 years. Statistics included multiple regression analysis, ANOVA, Kruskal-Wallis and chi-square tests.

RESULTS

Diagnostic groups differed with respect to sociodemographics, psychopathology and quality of life, but not with respect to mean level of social functioning. Despite between-group differences, the caregiver's burden did not differ according to the diagnostic group. Of the four dimensions of burden, "worrying" and "urging" scored the highest. Majority of caregivers worried about their relative's general health (82%), future (74%) and financial status (66%). Caregivers' characteristics and not patients' explained the largest proportion of the family burden variance (almost 23% for IEQ Tension). Higher burden seemed to be associated with the carer's age, being a parent and number of hours spent weekly on caring for the ill relative. Lower burden was associated with the carers' subjective feelings of being able to cope with problems and to pursue their own activities. Longer history of patient's illness led to higher IEQ Tension. Polish caregivers were affected by their role in the same way as their counterparts abroad, but more of them were worried.

CONCLUSIONS

The caregiver's burden seems to be independent of the patient's diagnosis, but other factors contribute to the perceived burden, many of which are on the caregiver's part. In Poland, the overall family burden may be attributed mostly to worrying about a mentally ill relative and his future. All caregivers may benefit from psychoeducation and family interventions usually planned for those caring for relatives with schizophrenia.

A comparison of levels of burden in Indian and white parents with a son or daughter with schizophrenia

BACKGROUND

Caregiver burden in mental illness is believed to differ between ethnic groups, but few studies have examined this in schizophrenia in the UK.

AIM

To measure burden in British North Indian Sikh and white British parents with a son or daughter with established schizophrenia managed in outpatient care.

METHOD

A cross-cultural cohort study measuring family factors, patient psychopathology and levels of burden and distress.

RESULTS

Overall levels of burden were low with no significant differences between the groups. Burden subscale scores showed Indian parents were more affected by psychotic behaviours than white parents. The groups also differed on several sociodemographic variables.

CONCLUSION

In stabilized community patients, the overall extent of burden experienced by both Indian and white parents is low and comparable. However, Indian parents were more burdened by psychotic behaviours. This may be a result of co-residence as Indian patients are more likely to live with their families. Social and economic factors in the country of residence and levels of acculturation may also influence levels of burden and the illness behaviours found most bothersome by parents.

Perceived burden in spouses of National Guard/Reserve service members deployed during Operations Enduring and Iraqi Freedom

Spouses of combat veterans with posttraumatic stress disorder (PTSD) experience elevated psychological distress. Recent research indicates that spouses' perceptions of burden may be one mechanism of such distress, but there are several gaps in this literature. No research has examined perceived burden in relation to symptoms other than PTSD or subclinical levels of psychological distress, and very little research has focused on characteristics of spouses that may be related to their perceptions of burden. The current study examined these variables in 130 spouses of reserve component troops deployed during Operations Enduring/Iraqi Freedom. Spouses' burden was positively associated with symptoms of PTSD, depression, and anxiety in service members, regardless of clinical severity. Moreover, burden fully mediated the relation between each type of symptom and spouses' own psychological distress. Furthermore, levels of burden were significantly related to spouses' neuroticism, avoidant coping, and self-efficacy, but only avoidant coping remained a significant predictor of burden when accounting for service members' distress. These results suggest that a broad range of service members' symptoms are related to spouses' burden and distress, and although individual characteristics of spouses may be related to their perceptions of burden, service members' symptoms play a primary role.

Personality factors and mental health outcome in caregivers of first hospitalized schizophrenic and depressed patients: 2-year follow-up results

While neuroticism has been intensely investigated in caregivers of patients with serious somatic disorders, studies in caregivers of patients with mental illness are lacking. Additionally, most studies are cross-sectional not allowing conclusions about long-term effects of personality factors. The present study examines the impact of personality factors on the course of subjective burden and psychological well-being by a mediational model in a sample of caregivers of first hospitalized patients with schizophrenia or depression within a 2-year follow-up period. At baseline, 83 caregivers could be enrolled in the study, the drop-out rate was about 23% at 2-year follow-up. Personality factors were assessed by the German version of the NEO-FFI (Borstenau and Costa 1993) only at baseline. At each follow-up, subjective burden was assessed by the FBQ (Möller-Leimkühler acc. to Pai and Kapur (Brit J Psychiat 138:332-335, 1981)), and psychological well-being by the SCL-90 R (Derogatis in SCL-90-R, administration, scoring and procedures. Manual for the r(evised) version. John Hopkins University School of Medicine, Baltimore, 1977). Among the personality factors, neuroticism turned out to be the most relevant predictor of subjective burden and self-rated symptoms, showing direct as well as indirect effects. The direct effects on caregivers' mental health were mediated to a considerable amount by subjective burden. The mediational model was stable across time and even revealed increasing indirect effects of neuroticism. Caregivers' neuroticism as a dispositional trait plays a crucial role in the course of the stress process. As neuroticism is associated with perceptual distortion, the latter should be targeted by long-term family interventions in order to reduce subjective burden and enhance mental health of the caregivers.

Illness-related components for the family burden of relatives to patients with psychotic illness

BACKGROUND

Previous research has shown that symptom severity often implies an increased family burden. Few other illness-related variables have, however, been investigated in this context. This study investigates how family burden is affected by symptom, function, and cognition, as well as how the patient perceives his/her illness and quality of life.

METHOD

A total of 99 relatives, to as many patients diagnosed with psychosis and with their illness at a stable level, participated in this study. The relatives estimated their perceived burden, the patients rated the distress caused by their illness as well as the quality of their lives, and the care staff rated the patients' symptom and function as well as tested their cognitive abilities.

RESULTS

Increased family burden can be tied to the patients' increased symptom severity, to their impaired functioning as well as to the patients' higher self ratings regarding distress. The family burden is also connected to the patient's reduced working memory and reduced executive functioning, but this connection is not totally clear and should be further investigated. Of the variables that the patients were rated on, it was the overall functional ability measured with GAF that had the single most impact on perceived family burden.

CONCLUSIONS

Controlling of illness-related variables, such as symptoms, impaired functioning, impaired working memory and executive functioning, as well as the patients' own experiences of distress, is important in order to lessen the burden for the relatives. All aspects of family burden are, however, not explained by these factors, which is why further research within this realm is required.

Differential predictors of critical comments and emotional over-involvement in first-episode psychosis

BACKGROUND

Little research has focused on delineating the specific predictors of emotional over-involvement (EOI) and critical comments (CC) in the early course of psychosis. The purpose of this study was to investigate the differential relationships of EOI and CC with relevant predictors in relatives of first-episode psychosis (FEP) patients.

METHOD

Baseline patient-related factors including psychotic symptoms, depression and duration of untreated psychosis (DUP) and carer attributes comprising CC, EOI, burden of care and carers' stress and depression were assessed in a cohort of 63 remitted FEP patients and their relatives. Carers were reassessed at 7 months follow-up.

RESULTS

Baseline analysis showed that EOI was more strongly correlated with family stress compared with CC, whereas CC yielded a stronger association with DUP than EOI. Carers' CC at follow-up was not significantly predicted by either baseline family stress, burden of care or patient-related variables. Conversely, baseline EOI predicted both family stress and burden of care at 7 months follow-up. Finally, family burden of care at follow-up was a function of baseline EOI and patients' depressive symptoms.

CONCLUSIONS

This study provides preliminary support to the postulate that EOI and CC may be influenced by separate factors early in the course of psychosis and warrant future research and therapeutic interventions as separate constructs. Implications for family interventions in the early phase of psychosis and the prevention of CC and EOI are discussed.

Esquizofrenia: dando voz à mãe cuidadora

Objetivou-se investigar as repercussões desencadeadas na vida de mães cuidadoras ao longo do curso do transtorno esquizofrênico de seus filhos. Doze participantes responderam a uma entrevista semiestruturada e suas narrativas foram examinadas por meio da análise de conteúdo temática. Foram encontrados sete eixos temáticos, cada qual apontando momentos, problemáticas e correlatos emocionais específicos: estranhamento, o estigma da loucura, a chegada ao consultório médico, o diagnóstico, resistindo ao tratamento médico, mudanças na vida, aceitação ou resignação. Os resultados evidenciaram a natureza invasiva do transtorno mental na vida da mãe cuidadora, a especificidade das sobrecargas vivenciadas em cada período do curso da esquizofrenia e a dificuldade encontrada na elaboração psíquica da condição do filho, mesmo após muitos anos do diagnóstico.