A concise self-report scale can identify high expressed emotions and predict higher relapse risk in schizophrenia

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Clinical trial registration

ClinicalTrials.gov, identifier NCT03688009.

Psychometric properties of the Chinese version of the Family Questionnaire among the caregivers of people with schizophrenia

Introduction

Expressed emotion refers to relatives' attitudes and emotional behaviors toward mentally ill family members. It is a robust predictor of patients' illness outcomes and caregivers' wellbeing in a wide range of mental disorders. However, expressed emotion has not been fully explored in the Chinese context. One reason is the lack of reliable and cost-effective measurements. A reliable, valid, and user-friendly instrument is needed to support the research and clinical practice based on expressed emotion in China. This study aimed to translate, adapt, and examine the psychometric properties (factorial structure, measurement invariance, internal consistency reliability, and concurrent validity) of a Chinese version of the Family Questionnaire.

Methods

A total of 248 caregivers participated in the study. A translation and back-translation procedure was applied to translate the Family Questionnaire into Chinese. We compared two models to examine the factor structure of the questionnaire by performing confirmatory factor analysis. We also conducted measurement invariance analysis to test whether the factor structure of the tool is invariant across male and female groups. Reliability was evaluated with Cronbach's α. The concurrent validity was examined by testing the predictivity of the expressed emotion on relevant outcomes with path analysis. We used the STROBE checklist to report.

Results

The item-total correlation coefficients of the scale ranged from 0.375 to 0.752. The confirmatory factor analysis indicated that the Chinese version of the Family Questionnaire displays the original two-factor structure (emotional overinvolvement and criticism; X² = 335.50, df = 169, X²/df = 1.985, RMSEA = 0.063, SRMR = 0.058, CFI = 0.913, and TLI = 0.902). In addition, the two-factor structure was invariant across the male and female groups. The two subscales showed excellent internal consistency, with Cronbach's alpha of 0.92 for both emotional overinvolvement and criticism. The concurrent validity of the Chinese version was supported by the good predictivity of the two subscales to care burden, family function, and quality of life. All path coefficients were significant, and the absolute values of path coefficients ranged from 0.23 to 0.72.

Conclusion

The Chinese version of the Family Questionnaire is a valid and reliable measurement of expressed emotion in the Chinese context.

The Effects of a Mindfulness-Based Family Psychoeducation Intervention for the Caregivers of Young Adults with First-Episode Psychosis: A Randomized Controlled Trial

OBJECTIVE

In this study, we investigated the effects of a mindfulness-based family psychoeducation (MBFPE) program on the mental-health outcomes of both caregivers and young adults with first-episode psychosis with an onset in the past three years through a multi-site randomized controlled trial. We also studied the outcomes of three potential mediating effects of interpersonal mindfulness, expressed emotions, and non-attachment on the program.

METHOD

We randomly assigned 65 caregivers of young adults with psychosis to MBFPE (n = 33) or an ordinary family psychoeducation (FPE) program (n = 32); among them, 18 young adults in recovery also participated in the evaluation of outcomes.

RESULTS

Intent-to-treat analyses were conducted. No significant time × group interaction effects of MBFPE and FPE programs were found in any of the caregivers' outcomes. However, the young adults with psychosis reported higher levels of recovery after the MBFPE program than after the ordinary FPE program (F = 8.268, p = 0.012, d = 1.484). They also reported a larger reduction in over-involvement of their caregivers (F = 4.846, p = 0.044, d = 1.136), showing that MBFPE had a superior effect to FPE in promoting recovery and reducing over-involvement.

CONCLUSIONS

A brief psychoeducation program may not reduce the burden on or improve the mental-health outcome of caregivers of individuals with recent-onset psychosis. However, integrating mindfulness into a conventional family psychoeducation program may reduce the expressed emotions of caregivers, especially over-involvement. Further studies should explore how psychoeducation programs can reduce the impact of psychosis on family through sustainable effects in terms of reducing their burden and expressed emotions, using a rigorous study and adequate sample size.

Survey of High Expressed Emotions Experienced By Community Mental Health Service Users in Hong Kong During the COVID-19 Pandemic

Background

High expressed emotion (EE) experienced by people with mental illness is a known risk factor of relapse. With drastically increased time spent at home and limited health and social service provision during the COVID-19 pandemic, patients’ experience of high EE warranted attention.

Aims and Methods

The study aimed to investigate the experience of high EE among people with mental illness during the COVID-19 pandemic. We surveyed the service users of 2 community mental health centers, including participants with psychotic and nonpsychotic disorders.

Results

Valid responses from 303 participants indicated an overall high EE prevalence of 71.62%, much higher than previous findings, which range between 30% and 40%. People with other psychotic and nonpsychotic disorders showed a higher probability of experiencing high EE than people with schizophrenia. Participants reported a higher probability of experiencing high EE as a result of caregiving by other family relatives and friends than by parents.

Conclusion

Findings suggest a significantly elevated high EE prevalence among people suffering from mental illness in the community during the COVID-19 pandemic. It is worth further evaluating the long-term effects of high EE beyond the pandemic.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

High level of expressed emotions in the family of people with schizophrenia: has a covert abrasive behaviours component been overlooked?

BACKGROUND

High expressed emotion (EE) in a patient's family is a known risk factor of relapse in schizophrenia. The three components of high EE - criticism, hostility and emotional over-involvement - were developed through a data-driven approach and a focus on overt abrasive behaviours. The influence of covert abrasive behaviours has not been explored.

AIMS AND METHODS

This study aims to explore both overt and covert abrasive behaviours through semi-structured interviews conducted with 22 people with schizophrenia, who were recruited through iterative purposive sampling.

RESULTS

Thematic analysis suggests that participants' experiences of overt abrasive behaviours resonate with the three-factor structure of high EE, except "emotional over-involvement" is renamed to "over-involvement" to focus on behaviours and embrace different levels or types of emotional reactions. Regarding covert abrasive behaviours, two domains are proposed: disassociation and apathy, which focus on family members' disengaging actions and indifferent attitudes respectively. While both overt and covert abrasive behaviours cause psychological distresses and behavioural reactions on the participants, their precise impacts are not entirely the same.

CONCLUSION

People with schizophrenia experience both overt and covert abrasive behaviours with family members. The findings of this study may expand the conceptualization of high EE, enhance its content validity, and provide an extended conceptual framework for developing more comprehensive measures.

A Brief Mindfulness-Based Family Psychoeducation Intervention for Chinese Young Adults With First Episode Psychosis: A Study Protocol

Family psychoeducation (FPE) has been recommended as a major component in the treatment of psychosis. Many previous studies have implemented an intensive program design that often only emphasized improvements in patients' illness outcomes but the benefits for caregivers were limited. There have been calls for a time-limited but cost-effective FPE program to mitigate the looming reality of the suffering of people with psychosis and their families. A Brief Mindfulness-Based Family Psychoeducation for psychosis program is developed to reduce caregivers' burden and promote young adult's recovery. A randomized controlled trial will be conducted to compare this intervention with an ordinary FPE intervention. Both arms will involve six sessions, with a total contact time of 12 h. 300 caregivers of young adults who have experienced first episode psychosis within last 3 years will be recruited. Program effectiveness will be assessed by comparing outcomes measuring the caregivers' burden, mental health symptoms, positive well-being, and the young adult's mental health symptoms during the study and at 9-month post-randomization. The role of expressed emotions, interpersonal mindfulness, and non-attachment in mediating these outcomes will be explored. An additional qualitative approach Photovoice is selected to explore the complex family experiences and the benefits of mindfulness from the caregivers' personal perspectives. Trial Registration: The trial is registered with the United States Clinical Trials Registry (ClinicalTrials.gov): NCT03688009.