Schizophrenia: Impact on Family Dynamics

"Sustaining the burden". A qualitative study on the emotional impact and social functioning of family caregivers of patients with psychosis

Evidence shows that caring for a family member with a psychotic disorder generates a significant emotional impact and repercussions on social functioning. However, this caregiving experience can be influenced by cultural factors. The aim of this study is to explore the experience and perception of a group of family caregivers of patients with psychotic disorders of different durations regarding the emotional and social functioning repercussions of caregiving on them in Andalusia. Three focus groups (28 participants) were conducted. Data were subject to a thematic analysis. Three themes emerged from the data: 1) Emotional invasion; 2) Disruption in the caregiver's life project; and 3) Changes in the family system. Participants reported experiencing sadness, fear, overwhelm, hopelessness, and uncertainty. Caregivers' accounts reflected an interruption of their daily tasks, as well as the need to reformulate plans or goals outside the family life that require long-term commitment, such as professional development or even their residence. The narratives indicated an impact on all roles within the family system, particularly for the mother. The results are consistent with existing research. Healthcare professionals and programs should take into account the costs associated with caregiving in order to minimize them, given the impact it has on both the patient's and the caregivers' health.

The relationship between perceived family support and subclinical positive symptoms of psychosis among Black college students

AIM

Black individuals in the Unites States endure compounded and unique experiences of discrimination and structural racism that may not be as overtly evident in other countries. These distinctive forms of discrimination and racism can impact the mental health of Black individuals in the Unites States, in this case, their risk for psychosis. Adolescence and early adulthood are vulnerable periods in life where mental illness typically begins to manifest. Understanding the factors contributing to an increased likelihood of specific mental illnesses, such as psychosis, among youth in these vulnerable periods can inform intervention development. This is particularly important for those from minoritized backgrounds Unites States; this group is especially important to study given that Black American youth tend to experience higher psychosis rates and different symptom presentations than non-Black groups.

METHODS

This study examined the associations between perceived family support, a critical environmental factor known to be associated with full-psychosis, and attenuated positive symptoms and distress levels in a sample of 155 Black students from a Historically Black College and University (HBCU). Participants completed the Prodromal Questionnaire-Brief that assessed psychosis risk and the Family Environment Scale that assessed three dimensions of family support (family cohesion, expressiveness, and conflict).

RESULTS AND CONCLUSION

Positive symptom intensity (r = .30, p < .001) and distress (r = .34, p < .001) were significantly associated with higher family conflict for Black individuals in the Unites States. The findings inform novel intervention targets for psychoeducation and family therapy that have potential to reduce psychosis risk.

Burden Experienced by Primary Caregivers of Children With Psychotic Disorders and at Clinical High Risk for Psychosis

BACKGROUND

Despite the existing research exploring caregiver burden in adult psychosis, few studies have examined the experience of providing care to children diagnosed with psychotic disorders (PDs) and those identified as having clinical high risk for psychosis (CHR-P).

AIM

This study measured the level of burden in caregivers of children with PD and CHR-P and examined associated risk factors, including social support, caregiver-child relationship, severity of illness, and frequency of psychiatric hospitalizations.

METHODS

A total of 56 caregivers completed validated measures and provided demographic information. Measures included the Zarit Burden Interview, the Multidimensional Scale of Perceived Social Support, the Behavior Assessment System for Children, Third Edition, Parenting Relationship Questionnaire-Child and Adolescent Form (BASC-3 PRQ-CA), and the Clinical Global Impression-Severity scale.

RESULTS

The majority of caregivers were women (86%), mothers (84%), White (63%), married (66%), working full-time (50%), college-educated (79%), and whose mean age was 45.7 years (SD = 8.09). Nearly half of the caregivers (45%) reported a high level of caregiver burden, 39% rated their burden in the mild to moderate range, and 16% reported little to no burden. There was no significant difference in mean burden between PD and CHR-P groups. Higher caregiver burden was associated with lower levels of social support (r = -.408, p = .002), lower levels of parenting confidence (r = -.514, p < .001), higher levels of relational frustration (r = .612, p < .001), and higher severity of illness (r = .316 p = .025).

CONCLUSIONS

These findings underscore the critical unmet need for support for caregivers of children with PD and CHR-P. Applications to clinical practice are discussed.

Effectiveness of an Uncertainty Management Psychoeducation Program for Schizophrenia Caregivers: A Randomized Controlled Trial

BACKGROUND

The inconsistent course of schizophrenia causes a long-term experience of uncertainty for individuals and their families. In Turkey, no studies yet exist that have attempted to address this constant uncertainty that is experienced by caregivers of schizophrenic patients.

AIMS

To evaluate the effects of the Uncertainty Management Psychoeducation Program on reducing uncertainty and intolerance to uncertainty, improving psychological well-being, and coping styles in caregivers of patients with schizophrenia.

METHOD

Single-blinded randomized controlled trial. Caregivers of schizophrenia inpatients were recruited from the psychiatry clinic of a university-affiliated hospital. Data were collected between April 2019 and August 2020. Eligible individuals were randomly allocated to one of the two groups: intervention or control. The intervention group had five individual psychoeducation sessions: "Recognizing Uncertainty," "Cognitively Reframing Uncertainty," "Solving Uncertainty-Related Issues," "Dealing with Uncertainty Using Communication Skills," and the "Closing Session." Participants in the control group received the usual care. Uncertainty, intolerance to uncertainty, psychological well-being, and stress coping strategies were measured at two points: at baseline and immediately following the intervention. Hypotheses were tested using the Mann-Whitney U and Wilcoxon tests.

RESULTS

A total of 54 participants were recruited. The intervention group's ratings for "seeking social support" and "optimistic approach" were higher than the control group's ratings. Significant within-group changes in terms of "uncertainty" and "optimistic approach" were reported for the intervention group in the post-intervention. In the control group, significant changes were seen in terms of "uncertainty" and "psychological well-being" over time.

CONCLUSION

The Uncertainty Management Psychoeducation Program was found to be effective in reducing the level of uncertainty, increasing their optimistic approach, and seeking social support of caregivers of schizophrenic patients.

Association between degree centrality and neurocognitive impairments in patients with Schizophrenia: A Longitudinal rs-fMRI Study

BACKGROUND

Evidence indicates that patients with schizophrenia (SZ) experience significant changes in their functional connectivity during antipsychotic treatment. Despite previous reports of changes in brain network degree centrality (DC) in patients with schizophrenia, the relationship between brain DC changes and neurocognitive improvement in patients with SZ after antipsychotic treatment remains elusive.

METHODS

A total of 74 patients with acute episodes of chronic SZ and 53 age- and sex-matched healthy controls were recruited. The Positive and Negative Syndrome Scale (PANSS), Symbol Digit Modalities Test, digital span test (DST), and verbal fluency test were used to evaluate the clinical symptoms and cognitive performance of the patients with SZ. Patients with SZ were treated with antipsychotics for six weeks starting at baseline and underwent MRI and clinical interviews at baseline and after six weeks, respectively. We then divided the patients with SZ into responding (RS) and non-responding (NRS) groups based on the PANSS scores (reduction rate of PANSS ≥50%). DC was calculated and analyzed to determine its correlation with clinical symptoms and cognitive performance.

RESULTS

After antipsychotic treatment, the patients with SZ showed significant improvements in clinical symptoms, semantic fluency performance. Correlation analysis revealed that the degree of DC increase in the left anterior inferior parietal lobe (aIPL) after treatment was negatively correlated with changes in the excitement score (r = -0.256, p = 0.048, adjusted p = 0.080), but this correlation failed the multiple test correction. Patients with SZ showed a significant negative correlation between DC values in the left aIPL and DST scores after treatment, which was not observed at the baseline (r = -0.359, p = 0.005, adjusted p = 0.047). In addition, we did not find a significant difference in DC between the RS and NRS groups, neither at baseline nor after treatment.

CONCLUSIONS

The results suggested that DC changes in patients with SZ after antipsychotic treatment are correlated with neurocognitive performance. Our findings provide new insights into the neuropathological mechanisms underlying antipsychotic treatment of SZ.

The complexities of suicide: a multilevel survival analysis examining individual, familial and neighbourhood determinants of suicide risk using Danish register-based data

BACKGROUND

Suicide risk is complex and nuanced, and how place impacts suicide risk when considered alongside detailed individual risk factors remains uncertain. We aimed to examine suicide risk in Denmark with both individual and neighbourhood level risk factors.

METHODS

We used Danish register-based data to identify individuals born in Denmark from 1972, with full parental information and psychiatric diagnosis history. We fitted a two-level survival model to estimate individual and neighbourhood determinants on suicide risk.

RESULTS

We identified 1723 cases of suicide in Denmark during the follow-up period from 1982 to 2015. Suicide risk was explained mainly by individual determinants. Parental comorbidities, particularly maternal schizophrenia [incidence rate ratio (IRR): 2.29, 95% CI 1.56-3.16] and paternal death (2.29, 95% CI 1.31-3.72) partly explained suicide risk when adjusted for all other determinants. The general contextual effect of suicide risk across neighbourhoods showed a median incidence rate ratio (MRR) of 1.13 (1.01-1.28), which was further reduced with full adjustment. Suicide risk increased in neighbourhoods with a higher proportion of manual workers (IRR: 1.08; 1.03-1.14), and decreased with a higher population density (IRR: 0.89; 0.83-0.96).

CONCLUSION

Suicide risk varies mainly between individuals, with parental comorbidities having the largest effect on suicide risk. Suicide risk was less impacted by neighbourhood, though, albeit to a lesser extent than individual determinants, some characteristics were associated with suicide risk. Suicide prevention policies might consider targeting interventions towards individuals more vulnerable due to particular parental comorbidities, whilst taking into account that some neighbourhood characteristics might exacerbate this risk further.

Hopefulness among individuals living with schizophrenia and their caregivers in Tanzania: an actor-partner interdependence model

BACKGROUND

Hopefulness is a positive orientation or state of mind that can aid in the recovery and treatment of mental illness, as it can have significant impacts on clinical and psychosocial outcomes. As resource-constrained settings work to implement recovery-oriented care, there is a need to better understand hopefulness among people living with schizophrenia (PLWS) and caregivers in their extended family networks. This study seeks to examine the dyadic relationship of hopefulness and its associated correlates among PLWS attending outpatient psychiatric clinics and their caregivers in Tanzania.

METHODS

This study utilized baseline and immediate post-intervention data collected as part of a randomized controlled trial testing a culturally tailored model of Family Psychoeducation, KUPAA, in Tanzania. The Herth Hope Index was used to measure hopefulness among PLWS (n = 33) and their caregivers (n = 33) at baseline and immediate post-intervention. Univariable and multivariable regression models were conducted to determine correlates of hopefulness at baseline, while the Actor-Partner Interdependence Model (APIM) was employed to examine the longitudinal, dyadic relationship of hopefulness among and between PLWS and their caregivers.

RESULTS

Better family functioning was associated with higher levels of hopefulness in PLWS and their caregivers. Lower levels of stigma, lower symptom severity, and lower disability were associated with higher levels of hopefulness in PLWS. For PLWS and their caregivers, actor effects from the APIM model were less than one (PLWS, [Formula: see text]; caregivers, [Formula: see text]), indicating stability (within each person) in hopefulness over time. Regarding partner effects, a caregiver's baseline hopefulness had a positive effect on the hopefulness of their PLWS at follow-up ([Formula: see text]). This indicates that higher caregiver hope at time 0 is associated with higher levels of hope in PLWS at time 1. Baseline hopefulness levels for PLWS had a negative effect on caregivers' hopefulness at follow-up ([Formula: see text]). This suggests that higher hopefulness among PLWS at baseline is associated with lower levels of hope in caregivers at follow-up.

CONCLUSION

Hopefulness is important to consider in family or caregiver-based treatments for PLWS because caregiver hopefulness may influence improvements in hopefulness among PLWS over time. Future studies should further explore the longitudinal dyadic relationship of hopefulness for these populations, as hope is a non-pharmacological and modifiable mechanism of change that is underutilized in care and treatment plans for PLWS globally.

TRIAL REGISTRATION

Clinical Trials #NCT04013932, July 10, 2019.

Experience, impact and needs of informal parental caregivers around the communication of a diagnosis of schizophrenia

AIMS

To qualitatively characterize the experience, impact and needs of informal family caregivers around the communication of a diagnosis of schizophrenia.

METHODS

In all, 13 informal family caregivers were recruited. All were parents. Semi-structured interviews were used to explore their experience of the diagnosis of schizophrenia, the impacts of the diagnosis and the needs related to the diagnosis around its communication. Interviews were recorded, transcribed, codes generated and mixed deductive-inductive thematic analysis undertaken.

RESULTS

Participants described receiving the diagnosis of schizophrenia for their relative as a devastating experience, although some nuanced the experience with a sense of relief of finally naming the disorder and getting access to care. Caregivers' experience and representations prior to hearing the diagnosis played an important role in the way the 'news' was internalized. The communication of the diagnosis constituted a starting point for acceptance of the reality of the illness in participants. Numerous unmet needs around the communication of the diagnosis were reported by participants, including personnalized support, specific explanations about the disorder and guidance on their role as caregiver.

CONCLUSION

A specific attention must be given to the communication of the diagnosis of schizophrenia to the informal family caregivers. Information giving must be early, comprehensive, personalized and embedded into tailored education and support programmes for caregivers to facilitate illness acceptance and adaptation.

Promoting Psychosocial Health of Family Caregivers of Patients with Chronic Mental Disorders: A Review of Challenges and Strategies

The present study aimed to investigate the mental and social health challenges of family caregivers of the patients with chronic mental disorders (CMD) and strategies which can be helpful in this regard. This study is a narrative review conducted in PubMed, Web of Science, Scopus, Elsevier, Google Scholar, Proquest, Magiran, and Sid databases where keywords such as Family caregiver, Chronic Mental disorder, Health Promotion, Program, Psychosocial, Support, Challenge, and Problem were searched in both Persian and English. A total of 5,745 published documents were found and were screened based on inclusion and exclusion criteria. Finally, 64 studies were found which had examined the related challenges, needs and strategies. According to the results, information deficits, needs for support, community participation deficits, and psychological suffering were recognized as challenges of family caregivers of these patients. Moreover, empowerments programs for the enhancement of the knowledge and skills of caregivers and peer-centered support programs were used to improve the level of mental and social health of family caregivers of these patients. Psychosocial problems and challenges that family caregivers of the patients with CMD face affect their health, satisfaction and quality of life. Using a collaborative approach, mental health service providers and government systems can help improve the psychosocial health of caregivers. The related managers and policymakers can reduce the emotional and psychological burden of families and promote their psychosocial health through developing a comprehensive program including practical objectives and strategies and taking into account the challenges that exist for caregivers in caring for patients with CMD.

Perceived mental health and emotional trajectories of long-term family caregivers of persons with mental conditions: A mixed-methods study

AIMS AND OBJECTIVES

To explore the emotional experience and the perceived mental health of experienced family caregivers of people with mental disorders.

BACKGROUND

Family caregiving for individuals with mental disorders differs from other health conditions, as it implies a burden, deterioration in physical and mental health, stigma and a perceived lack of support from mental health services.

METHODS

A mixed-method study was undertaken with family caregivers of people diagnosed with mental disorders.

RESULTS

A total of 13 experienced family caregivers were included in the study. The qualitative data were classified into two major themes: emotions and perceived mental health. Emotions included five categories: irritability, painful emotions, pressure, emotions orientated towards coping, and positive emotions. The perceived mental health status embraced five categories: anxiety, burden and exhaustion, needing psychological or psychiatric treatment, insomnia and suicidal thoughts. An emotional path could be constructed from their discourses, starting with lack of control or irritation that evolved towards resignation, peace or satisfaction. The quantitative analysis partially replicated the qualitatively reported anxiety, depressive symptoms and insomnia.

CONCLUSION

Past and present emotions related to caregiving described by experienced family caregivers were identified. Their emotional trajectories converged in that negative emotions gave way to emotions towards coping, which in turn were followed by positive emotions. The participants' descriptions about their mental status were partially reflected through objective mental health measurements.

RELEVANCE TO CLINICAL PRACTICE

More support from mental health services could help caregivers to progress in their emotional trajectory towards coping, and improve their caregiving knowledge and skills. Mental health nurses have a role in patients and caregivers education and in the promotion of caregivers' psychological wellbeing.

Requirements of caregivers of patients with schizophrenia: A qualitative study in Turkey

Caregivers have different experiences and difficulties in the patient care process during which the role of providing care is fulfilled. Understanding the requirements of caregivers may help determine the content of the country-specific psychoeducation program needed. Caregivers of patients with schizophrenia want certain needs to be met while they provide care to these patients. This qualitative study aims to determine and analyze these needs. The researchers conducted face-to-face semi-structured interviews with 15 caregivers. Themes were Themes identified included determined as managing disease behavior, gaining independent living skills, managing social-educational problems, and psychosocial support needs of the family members. Mental health and psychiatric nurses should understand, accept, and protect the needs of caregivers. It is suggested that mental health and psychiatric nurses plan group training about the determined needs and provide support for caregiving family members.

Automatic recognition of schizophrenia from facial videos using 3D convolutional neural network

Schizophrenia affects patients and their families and society because of chronic impairments in cognition, behavior, and emotion. However, its clinical diagnosis mainly depends on the clinicians' knowledge of the patients' symptoms. Other auxiliary diagnostic methods such as MRI and EEG are cumbersome and time-consuming. Recently, the convolutional neural network (CNN) has been applied to the auxiliary diagnosis of psychiatry. Hence, in this study, a method based on deep learning and facial videos is proposed for the rapid detection of schizophrenia. Herein, 125 videos from 125 schizophrenic patients and 75 videos from 75 healthy controls based on emotional stimulation tasks were obtained. The video preprocessing included the experiment clips extraction, face detection, facial region cropping, resizing to 500 × 500 pixel size, and uniform sampling of 100 frames. The preprocessed facial videos were used to train the Resnet18_3D. We utilized ten-fold cross-validation, and held-out testing set to evaluate the model with the accuracy, the precision, the sensitivity, the specificity, the balanced accuracy, and the AUC. The Resnet18_3D trained on Film_order achieved the best performance with accuracy, sensitivity, specificity, balanced accuracy, and AUC of 89.00%, 96.80%, 76.00%, 86.40% and 0.9397. The neural network model indeed recognizes healthy controls and schizophrenic patients through the changes in the area of the face. The results show that facial video under emotional stimulation can be used to classify schizophrenic patients and help clinicians with diagnosis in the clinical environment. Among the different types of stimuli, the video stimuli with fixed emotional order showed the best classification performance.

Management of schizophrenia in women during the perinatal period: a synthesis of international recommendations

INTRODUCTION

The perinatal period in schizophrenia is associated with high risk of psychotic relapse and pregnancy/child outcomes. The extent to which antipsychotics may potentially affect the fetus or the child development is unclear and debated. Even though guidelines have been developed, there is a lack of consensual recommendations regarding the optimal strategy to manage schizophrenia during the perinatal period.

AREAS COVERED

This systematic review describes the current state of evidence with respect to the impact of recommended interventions for schizophrenia during the perinatal period, including childbearing age, pregnancy and post-partum. It compares recent international treatment guidelines for this specific group of women. Last, this review presents a set of major points to be discussed with patients and relatives for shared-decision making and a summary of key recommendations from the international guidelines.

EXPERT OPINION

Although treatment guidelines may be of significant help, discrepancies exist across them regarding the management of antipsychotics for schizophrenia women during the perinatal period. Shared decision-making and advance directives represent useful patient-centered approaches during this specific period. Further cohort-based evidence is needed to better identify maternal and fetal risks associated to antipsychotic treatment exposure.

Fear of relapse in schizophrenia: a mixed-methods systematic review

INTRODUCTION

Fears of relapse in people diagnosed with schizophrenia have long been recognised as an impediment to recovery and wellbeing. However, the extent of the empirical basis for the fear of relapse concept is unclear. A systematic review is required to collate available evidence and define future research directions.

METHODS

A pre-registered systematic search (PROSPERO CRD42020196964) of four databases (PubMED, MEDLINE-Ovid, PsycINFO-Ovid, and Cochrane Central Register of Controlled Trials) was conducted from their inception to 05/04/2021.

RESULTS

We found nine eligible studies. Five were quantitative (4 descriptive and 1 randomised controlled trial), and four were qualitative. The available quantitative evidence suggests that fear of relapse may have concurrent positive relationships with depression (r = 0.72) and suicide ideation (r = 0.48), and negative relationship with self-esteem (r = 0.67). Qualitative synthesis suggests that fear of relapse is a complex phenomenon with behavioural and emotional components which has both direct and indirect effects on wellbeing.

CONCLUSIONS

Evidence in this area is limited and research with explicit service user and carer involvement is urgently needed to develop new and/or refine existing measurement tools, and to measure wellbeing rather than psychopathology. Nonetheless, clinicians should be aware that fear of relapse exists and appears to be positively associated with depression and suicide ideation, and negatively associated with self-esteem. Fear of relapse can include fears of losing personal autonomy and/or social/occupational functioning. It appears to impact carers as well as those diagnosed with schizophrenia.

Effectiveness of a brief family strengths-oriented therapeutic conversation intervention for patients with schizophrenia and their caregivers

PURPOSE

To examine the effects of a brief family strengths-oriented therapeutic conversation (FAM-SOTC) intervention on symptom severity of patients with schizophrenia and family coping and caregiver burden for family caregivers.

DESIGN

A quasi-experimental research design with repeated measures.

METHODS

A convenience sample of 72 dyads of patient-family caregivers was recruited from randomized inpatient psychiatric rehabilitation units in a psychiatric hospital in Taiwan. Sixty-one patient-family caregiver dyads that comprised the intervention group (n = 29) and control group (n = 32) completed questionnaires at four time points (baseline, immediate, one- and three-months post-intervention). Demographic questionnaires and clinical information, Brief Psychiatric Rating Scale, Family Crisis-Orientation Personal Evaluation Scales, and Zarit Burden Interview were used to collect data. Generalized estimating equations were used to assess the differences in symptom severity, family coping, and caregiver burden between the two groups.

FINDINGS

As compared to the control group, the intervention group showed statistically significant improvements over three months in symptom severity as well as family coping, especially acquiring social support, reframing, and mobilizing social support for family caregivers. Caregiver burden in the intervention group was ameliorated immediately and one month after the intervention rather than a three-month post-intervention.

CONCLUSIONS

A brief FAM-SOTC intervention proved to be favorable for alleviating psychiatric symptoms of patients coupled with an improvement in family coping and burden in family caregivers encountering schizophrenia.

CLINICAL RELEVANCE

Integration of a brief family therapeutic conversation intervention into the routine psychiatric rehabilitation services delivery is recommended to help patients and their family caregivers effectively manage schizophrenia.

A Systematic Review of Methods and Study Quality of Economic Evaluations for the Treatment of Schizophrenia

Background: Schizophrenia is a severe and complex disease with substantial economic and social burdens. Despite multiple treatment choices, adverse events, and impaired social functions are still challenges in clinical therapy. Pharmacoeconomic evaluations could provide evidence to help decision makers improve the utilization of scarce resources. However, there remains some challenges especially in modeling due to uncertainties in progression of schizophrenia. There are limited summaries about the overall methodologies of schizophrenia economic evaluations.

Objective: The aim of this study is to review the existing economic evaluations of antipsychotics for the treatment of schizophrenia and summarize the evidence and methods applied.

Methods: An electronic literature search was performed in PubMed, Web of Science, EBSCO host, The Cochrane Library and ScienceDirect from January 2014 to December 2020. Search terms included “schizophrenia,” “schizophrenic,” “pharmacoeconomic,” “economic evaluation,” “cost-effectiveness,” and “cost-utility.” The Literature was screened and extracted by two researchers independently and assessed with the Quality of Health Economic Studies (QHES) List and Consolidated Health Economic Evaluation Reporting Standards (CHEERS) Statement.

Results: A total of 25 studies were included in the review. The regions included Europe, North America, Asia and Africa. Most of the studies chose second-generation antipsychotics as comparators and integrated treatment sequences. Time horizons varied from 1 year to lifetime. The healthcare sector was the most common perspective, accordingly, most of the evaluations considered only direct medical costs. The Markov model and decision tree model were the most common choices. Adverse events, compliance and persistence were considered important parameters. Quality-adjusted life-years were the major outcomes applied to the economic evaluations. All utilities for health states and adverse events were collected from published literature. All of the studies applied uncertainty analysis to explore the robustness of the results. The quality of the studies was generally satisfactory. However, improvements were needed in the choice of time horizons, the measurements of outcomes and the descriptions of assumptions.

Conclusions: This study highlights the methodology of economic evaluation of schizophrenia. Recommendations for modeling method and future study are provided.

Schizotypal personality disorder and suicide: problems and perspectives

Schizotypal personality disorder (SPD) is classified in DSM-V as a cluster A personality disorder. Cluster A personality disorders are described as odd or eccentric conditions. SPD is associated with significant disability and many psychiatric comorbidities. Several studies have shown that SPD and schizotypal traits are associated with suicidal ideation and behaviour. Suicide prevention interventions in individuals with SPD are impeded because (1) SPD is frequently not diagnosed; (2) SPD is difficult to treat; and (3) there are no guidelines for suicide screening or suicide prevention interventions in individuals with SPD. Suicide prevention in persons with SPD consists of (1) diagnosing SPD; (2) providing appropriate treatment for SPD; and (3) providing suicide screening and suicide prevention. Interventions aiming at reduction of depressive symptoms, improvement of self-esteem, and interpersonal skills may be effective at reducing suicide risk amongst individuals with SPD. Studies of suicidality in persons with SPD are needed and may be an important area of suicide research. It is to be hoped that future studies of the pathophysiology of suicidality in individuals with SPD will help to develop strategies for suicide screening and suicide prevention interventions in persons with SPD and improve suicide prevention in this challenging patient population.

Influence of Family Dynamics on Stigma Experienced by Patients With Schizophrenia: Mediating Effect of Quality of Life

Background: Stigma is a barrier to schizophrenia recovery; thus, screening the factors that affect stigma experienced by patients with schizophrenia and exploring the interactions between each factor are critical for improved treatment. The purpose of this study was to demonstrate the relationship between quality of life (QoL), family dynamics, and stigma in patients with schizophrenia. Methods: A total of 447 participants with schizophrenia were recruited in the study, namely, 281 community patients and 166 inpatients. Three scales, Schizophrenia Quality of Life Scale (SQLS), Self-rating Scale of Systemic Family (SSFD), and Stigma Scale for Mental Illness (SSMI), were, respectively, used to evaluate three variables: QoL, family dynamics, and stigma. The correlations between each factor in these three scales were evaluated by Spearman's rank correlation analysis. A mediation model was constructed to investigate whether QoL mediated the relationship between stigma and family dynamics. Results: Correlation analysis revealed that most variables in these three scales correlated significantly with each other. Mediational regression analyses indicated that the degree of stigma was affected by family dynamics; that is, good family dynamics predicted less stigma. Surprisingly, we found that a worse QoL was associated with less stigma, and this led to good family dynamics being related to a worse QoL. These findings further suggested that QoL had a mediating effect on the relationship between family dynamics and stigma. Conclusions: This study suggested that more attention should be focused on the multifactorial influence of stigma on patients with schizophrenia. Integrated and personalized interventions regarding QoL and family dynamics can be tailored for patients with schizophrenia to reduce self-stigma.

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

WHAT IS KNOWN ON THE SUBJECT

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

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

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

WHAT ARE THE IMPLICATIONS FOR PRACTICE

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

ABSTRACT

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

AIM/QUESTION

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

METHODS

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

RESULTS

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

IMPLICATIONS FOR PRACTICE

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

Family Coping Strategies to Improve the Health of Family Members Living with Schizophrenia

Introduction: Schizophrenia is a serious mental illness that affects the thinking, emotions, relationships, and decision-making. One of the positive effects of treating schizophrenia in patients is family health. The family welfare management strategies provide help for coping, care preparation, organizing meetings, and mentoring. This study focuses on family coping strategies for improving the health of members living with schizophrenia.Methods: A cross-sectional design was used by choosing 160 respondents randomly. The inclusion criteria were family members accompanying control schizophrenia patients to the Public Health Center, with a minimum age of 18. The independent variable was family coping, which consist of two sub-variables (problem-focused coping mechanism and emotion-focused coping mechanism), while the dependent variable was family health, which consists of three sub-variables (efficient, satisfaction, and happiness). The SMART PLS (2.0 Version) was used to prove the impact of the variables.Results: The results indicated that family coping had a significant impact  on the health of the family. The hypothesis was taken from the value of the T-test on the structural model analysis, which shows T- statistics (13.966) > T-critical (1.96). The impact of family coping on the health is equal to 0.682 (OR). This means that if family coping is given one-unit value, it will increase the family health by 0.682 times.Conclusion: The implementation of the family coping strategy will improve the capacity of the family to clarify health issues encountered, resolve family behaviors effectively and minimize risk factors. Furthermore, the coping mechanisms chosen by families in facing stress will have an impact on the reduction of illness symptoms in the members with schizophrenia.

Feasibility of brief distress screening for family caregivers of adults diagnosed with schizophrenia in Changsha, Hunan, China

What is known on the subject? Distress screening amongst FGs is emphasized in worldwide studies, but existing general tools were found time-consuming and sometimes inconvenient when using them amongst FGs of patients diagnosed with schizophrenia. The DT, a single-item scale, was widely used to detect distress amongst FGs of cancer patients, showing good reliability, validity and discrimination power. The 21-item Depression Anxiety and Stress Scale (DASS21) can identify distress in the general population and serve as a criterion to determine an optimal cut-off score of the DT. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: The DT presented good reliability, validity and discriminatory power amongst FGs of adults diagnosed with schizophrenia. A cut-off score of six maximized sensitivity (77%) and specificity (76%). Over half of the FGs of adults diagnosed with schizophrenia reached this cut-off score and experienced significant distress. Distress was higher in FGs of male patients, when FGs were parents, and for FGs whose educational background was primary school or below. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The DT is an effective alternative to existing instruments in identifying distressed FGs of adults diagnosed with schizophrenia. It is important to provide FGs with distress screening programmes and interventions (e.g. skill-building psychoeducation) to identify and relieve distress. In addition, future research could explore brief measures to simultaneously recognize potential negative and positive impacts of caregiving in FGs.

Barriers to Family Resilience in Caregivers of People Who Have Schizophrenia

PURPOSE

To explore the barriers to family resilience in caregivers of people who have schizophrenia.

DESIGN

A qualitative descriptive approach was used.

METHODS

Semistructured interviews were conducted with family caregivers of patients with schizophrenia registered at the psychiatry outpatient unit of a hospital center. Content analysis was performed on audio-recorded and verbatim-transcribed interviews. The consolidated criteria for reporting qualitative research (COREQ) checklist was applied to this study.

RESULTS

A total of 31 family caregivers participated, the majority of whom were female (71%) with an average age of 57.5 years. Most participants lived with and cared for their relative (90.3%). The caregiver role was assumed mostly by mothers (54.8%) and fathers (22.6%). Barriers to family resilience in caregivers of people experiencing schizophrenia broadly fall under five categories: lack of knowledge about the disease, social stigma, expressed emotion, involvement in the relationship, and blame.

CONCLUSIONS

In view of the paucity of studies exploring and understanding the barriers to family resilience, this study presents itself as one of the first in this area. There are different barriers to family resilience. This research provides an overview and an understanding of key barriers to family resilience in caregivers of people experiencing schizophrenia.

CLINICAL RELEVANCE

There is a need for nurses to help families to be resilient. By understanding the barriers to resilience, nurses are able to focus on these factors and help families to remove or reduce their influence.

Focusing on quality of life in the family caregivers of patients with schizophrenia from the perspective of family functioning: A cross-sectional study

The study aimed to explore the association between family functioning and quality of life (QOL) in family caregivers of patients with schizophrenia.Totally 121 family caregivers were surveyed in the cross-sectional study by the self-administration questionnaires about sociodemographic characteristics, family functioning and QOL. Family functioning was evaluated in terms of the family assessment device and the Family Adaptability and Cohesion Evaluation Scale II China Version. QOL was evaluated in terms of TSDHE short-form 12-item health survey, version 2. Multiple regression models were built to explore the association between QOL and family functioning.A regression analysis showed that poorer physical health of family caregivers was significantly associated with the lower educational level of caregivers, the closer kinship with patients and the multiple episodes schizophrenia. The other regression analysis showed that better family adaptability and affective responsiveness were significantly associated with the better mental health of family caregivers.Family functioning is associated with mental health rather than the physical health of family caregivers. Psychoeducational intervention could focus on family caregivers with a lower educational level and closer kinship, and those who look after patients with multiple episodes schizophrenia. Further family intervention could focus on family adaptability and affective expression in family caregivers of patients with schizophrenia.

Family achievements in struggling with schizophrenia: life experiences in a qualitative content analysis study in Iran

BACKGROUND

The challenges of living with and taking care of a patient with schizophrenia can lead to positive changes depending on the experiences and reactions of family caregivers. Such changes may directly affect the family performance and the patient's recovery stage. Present study aimed to explain the positive experiences reported by family caregivers of patients with schizophrenia.

METHODS

The present study is a qualitative study of content analysis. Data were collected using semi-structured and in-depth interviews with 15 family caregivers of patients with schizophrenia referring to one of the psychiatric hospitals in Zahedan, Southeast part of Iran. Purposive sampling method was applied and data analysis was conducted using conventional content analysis proposed by Graneheim and Lundman.

RESULTS

Data analysis created a theme entitled "family achievements in struggling with schizophrenia". This theme included four categories including Developing positive personality traits in family members, Strengthening family ties, developing insight into the life, and social mobility.

CONCLUSIONS

The results provided insights that the experience of taking care of patients with schizophrenia led to positive consequences for family caregivers. Thus, it is recommended that psychiatrists or consultants help families rely on positive experiences and share these experiences with families with a newly-suffered patient.

Factors associated with family functioning among people with a diagnosis of schizophrenia and primary family caregivers

WHAT IS KNOWN ON THE SUBJECT?: Families act not only as the primary support for people with a diagnosis of schizophrenia but also as partners in the healthcare system. Families who have members with mental disorders, particularly schizophrenia, experience challenges in family functioning. Research on families in relation to schizophrenia primarily focuses on the determinants that affect family functioning from primary family caregivers' perspectives. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: This report provides evidence that there is a concordance between family functioning and inpatient psychiatric rehabilitation facilities for the patient-caregiver dyad; both care-receivers and primary family caregivers considered family functioning as poor. Care-receivers with lower education levels, increased number of previous hospitalizations and poor quality of family-centred care experienced unhealthy family functioning. Primary family caregivers and care-receivers with higher education levels, lower suicidality and greater quality of family-centred care experienced healthier family functioning. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Understanding the degree of family functioning, particularly its concordance and correlates as perceived by patients and primary family caregivers, may serve as a platform for inculcating assessment of family functioning to achieve holistic patient care. Open dialogue in family-focused care planning is essential to facilitate collaborative partnerships and improve family functioning among people with a diagnosis of schizophrenia and their primary family caregivers. Further research on culturally relevant, evidence-based family interventions to enhance the functioning of affected families is warranted, especially for families with members in inpatient psychiatric rehabilitation facilities. ABSTRACT: Introduction Families provide frontline caregiving support for people with a diagnosis of schizophrenia. However, research primarily addresses correlates of family functioning from primary family caregivers' perspectives. Aim To examine perceived family functioning, particularly its concordance within patient-caregiver dyads and associated factors in families of people living with schizophrenia. Methods A cross-sectional, descriptive correlational design was used. A total of 133 dyads of patients and primary family caregivers from inpatient psychiatric rehabilitation services participated. Descriptive statistics, independent-sample t test, one-way ANOVA, Pearson's correlation coefficients, intraclass correlation coefficient and stepwise multiple linear regression analyses were applied. Results Family functioning was perceived as impaired by patient-caregiver dyads, and there existed a concordance in this regard. Patients' and family caregivers' education levels, patients' suicidality, number of previous hospitalizations and quality of family-centred care correlated with patients' and primary family caregivers' family functioning. Discussion Findings highlight the importance of patient- and family-reported family functioning with implications to address individual and collective concerns. Implications for Practice Evidence-based family interventions are crucial for assisting vulnerable families in promoting family functioning. Mental health nurses should facilitate collaboration and open dialogue concerning perspectives of patients and families to improve delivery of comprehensive mental health care.

Basic Family Relations, Parental Bonding, and Dyadic Adjustment in Families with a Member with Psychosis

The aim of the current study is to describe and explore basic family relations, parental bonding, and dyadic adjustment in families with offspring diagnosed with a psychotic disorder. The sample was made up of 120 participants, 60 in the clinical group (GCL) and 60 in the comparison group (GCP). All participants were assessed using the basic family relations evaluation questionnaire (CERFB), the parental bonding instrument (PBI), and the dyadic adjustment scale (DAS). The results showed differences between the clinical and comparison groups in terms of perceptions of basic family relations, dyadic adjustment and parental bonding. The clinical group recorded less favorable results for all of these variables. More specifically, the study observed significant differences between the groups in parental function, overprotection and caring. This study deepens our understanding of how family assessment and relational diagnoses can serve as prevention and intervention tools for families affected by a psychotic disorder.

Shared decision-making in serious mental illness: A comparative study

OBJECTIVE

To compare consumer and mental health professionals' (MHPs) preferences for decision-making in China and Europe.

METHODS

This study used cross-sectional design; Chinese data were collected by questionnaires and European data were obtained from the literature. Data were analysed using t-test, One-way ANOVA and Pearson correlation coefficient as appropriate.

RESULTS

This study involved 800 people diagnosed with severe mental illness and 506 MHPs. Chinese participants rated lower scores on preference for participation in decision-making (PD = 1.88) and information (IN = 2.70) than European participants (PD = 2.05, IN = 2.83). Chinese consumers rated a higher score on IN (2.78) but lower on for PD (1.75) than MHPs (IN = 2.64, PD = 1.97). Chinese consumers' education level is positively associated with preference for PD and IN. The gender, occupation and age of Chinese MHPs are associated with preference for PD.

CONCLUSION

Both Chinese and Europeans had preference for shared involvement in mental health, while the preference in China is less. Opinions of consumers and MHPs might be different, regarding the level of patient involvement in specific decisions.

PRACTICE IMPLICATION

It is essential that consumers' preferences are understood for provision of optimal support for a shared decision-making approach.

'I wanted my child dead' - Physical, social, cognitive, emotional and spiritual life stories of Turkish parents who give care to their children with schizophrenia: A qualitative analysis based on empowerment approach

BACKGROUND

Schizophrenia deeply affects both the lives of patients and their families. The fact that schizophrenic patients in Turkey generally maintain their lives with their families may lead to serious problems for families and parents.

AIMS

The main purposes of this research are to determine the physical, social, cognitive, emotional and spiritual lives of parents of children with schizophrenia with the main concepts of the empowerment approach.

METHOD

The research was carried out with the qualitative research method. In-depth interviews were conducted with 30 parents in total, that is, 15 mothers and 15 fathers, through semi-structured interview form. Maxqda 2018 was used for the analysis of the research data.

RESULTS

According to the research result, it is determined that the parents have problems due to physical, social, cognitive, emotional and spiritual disease process; gender perspective and roles; domestic functionality; social environment, social perception; and issues related to services.

CONCLUSION

Considering the parents who are affected by the disease process which is a particularly quite difficult process and who affect the process, to recognize the situations that lead them to gain strength and that make them powerless in personal, interpersonal and political aspects, to activate the existing resources and to create new resources are highly important factors for them to cope with the disease process effectively.

PROFESSIONAL-FAMILY COMMUNICATION IN A CHILDREN’S PSYCHOSOCIAL CARE CENTER: PRACTICALITIES AND DIFFICULTIES

ABSTRACT Objective: to analyze the perceptions of the family members of users of a children’s psychosocial care center, regarding the facilitating factors and the difficulties in the communication with the health professionals. Method: a qualitative and descriptive study conducted with 25 family members of users of a children’s psychosocial care center in a city of Minas Gerais (Brazil). Data collection took place between April and July 2017 using focus groups and a semi-structured script for the implementation of group sessions. Data was analyzed according to content analysis, thematic category. Results: two categories emerged from the analysis: Professional-Family relationship and Suggestions to enhance communication, which included practicalities and difficulties in communication. The data showed that the professional-family relationship refers to the professionals’ positive actions, which facilitate communication, and to their negative actions, which means offering a distant and dehumanized care and failing to provide guidance. The suggestions to enhance communication were directed to the interventions focused on the family and on the dynamics and management of the service. Conclusion: there is a need for collaboration among management, staff and family members, which can contribute to a better health care and to building more solidary and dialogical relationships.

Burden for Parents of Patients With Schizophrenia-A Nationwide Comparative Study of Parents of Offspring With Rheumatoid Arthritis, Multiple Sclerosis, Epilepsy, and Healthy Controls

BACKGROUND

The study aimed to (1) compare the risk of health care use, adverse health status, and work productivity loss of parents of patients with schizophrenia to parents of patients with multiple sclerosis (MS), rheumatoid arthritis (RA), epilepsy, and healthy controls; and (2) evaluate such outcome measures while considering disease severity of schizophrenia.

METHODS

Based on linkage of Swedish registers, at least one parent was included (n = 18215) of patients with schizophrenia (information 2006-2013, n = 10883). Similarly, parental information was linked to patients with MS, RA, epilepsy, and matched healthy controls, comprising 11292, 15516, 34715, and 18408 parents, respectively. Disease severity of schizophrenia was analyzed. Different regression models yielding odds ratios (OR), hazard ratios (HR), or relative risks (RR) with 95% confidence intervals (CI) were run.

RESULTS

Psychiatric health care use, mainly due to anxiety and affective disorders, showed a strongly increasing trend for parents of patients with schizophrenia throughout the observation period. During the follow-up, these parents had an up to 2.7 times higher risk of specialized psychiatric health care and receipt of social welfare benefits than other parents. Parents of the moderately severely ill patients with schizophrenia had higher risk estimates for psychiatric health care (RR: 1.12; 95% CI: 1.07-1.17) compared with parents of least severely ill patients.

CONCLUSIONS

Parents of patients with schizophrenia have a considerably higher risk of psychiatric health care and social welfare benefit receipt than other parents. Psychiatric health care use worsens over time and with increasing disease severity of the offspring.

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.

Calidad de vida en pacientes con esquizofrenia de origen Aymara en la zona Centro-Sur de los Andes

El objetivo de este estudio consistió en comparar la calidad de vida (CV) de pacientes con esquizofrenia pertenecientes al grupo étnico aymara de los Andes Centro-Sur, con pacientes no Aymara. En este estudio transversal participaron 253 pacientes de tres clínicas de salud mental en Chile, Perú y Bolivia. Se recogieron datos sociodemográficos y características clínicas. La calidad de vida se evaluó utilizando el Cuestionario S-QoL18. Los análisis comparativos exploraron las diferencias de QoL entre los pacientes Aymara y no Aymara. Los participantes de origen Aymara tuvieron puntuaciones de CV más bajos en comparación con los pacientes no Aymara para el Índice total, las relaciones familiares y la dimensión de vida sentimental. Los ingresos familiares mensuales y la duración del trastorno fueron significativamente más bajos en los pacientes Aymara. Nuestro estudio soporta la hipótesis de una peor CV en pacientes aymaras con esquizofrenia.