Effectiveness of enhancing contact model on reducing family caregiving burden and improving psychological wellbeing among caregivers of persons with schizophrenia in rural China

Effects of Psychoeducation on Caregivers of Individuals Experiencing Schizophrenia: A Systematic Review and Meta-Analysis

The existing paradigm on recovery in mental health prioritises self-empowerment and person-centred, community-based care, which necessitates family caregivers' collaboration to support individuals with schizophrenia in the community. However, the role of family caregivers is often under-recognised and hence insufficiently supported. This consequently compromises caregivers' well-being and, ultimately, the recovery of individuals with schizophrenia. Although caregiver-targeted psychoeducation may offer practical support, its effectiveness lacks conclusive evidence. This review aimed to evaluate the impacts of psychoeducation on caregiver-related outcomes (caregiver burden, quality of life and expressed emotion). Eight electronic databases were searched from inception to September 2023, supplemented by hand searching of end-reference lists. Two reviewers independently conducted title and abstract screening with predetermined eligibility criteria. A third reviewer was consulted to resolve any discrepancies. A random-effects meta-analysis was performed to estimate pooled effect sizes alongside subgroup and sensitivity analyses where appropriate. Twenty-one studies (totalling 1639 caregivers) were included, based on which psychoeducation contributed to a statistically significant improvement in caregiver-related outcomes. Given substantial heterogeneity, subgroup and sensitivity analyses were done for the durations and the evaluative scales for psychoeducation. Quality appraisal revealed unclear or high bias in most studies. Notwithstanding the heterogeneity, the directions of the effect sizes consistently indicated the effectiveness of psychoeducation across all outcomes. This finding aligned with Lazarus' stress appraisal and coping theory, which states that psychoeducation improves caregivers' knowledge, coping mechanisms and situation appraisal. Our findings offer encouraging evidence to advocate the integration of psychoeducation into healthcare services, but policy-based support is warranted for sustained implementation. Further research is merited to optimise its duration and content and appraise its long-term impacts through disease-specific scales for objective and subjective outcomes.

Effectiveness of psychological interventions for carers of patients with severe mental illness (SMI): a systematic review

OBJECTIVES

Interventions for carers of patients with severe mental illness (SMI) are effective in improving patient outcomes. This review examined the effectiveness of psychological interventions or support designed to help carers of patients with SMI.

DESIGN

A systematic review of randomised controlled trials (RCTs) was conducted. Study selection, data abstraction and risk of bias assessments were independently conducted and duplicated. The reporting of this review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

DATA SOURCES

CINAHL, CENTRAL, EMBASE, Medline and PsycINFO were searched from inception to 30 April 2024.

ELIGIBILITY CRITERIA

Only studies using an RCT were considered. All other research designs were excluded. The included population was carers over 18 caring for a patient with SMI. Any psychological, psychosocial or psychoeducational interventions were included. Patients under 18, diagnosed with dementia or learning disabilities comorbidity, were excluded.

DATA EXTRACTION AND SYNTHESIS

Study characteristics and outcome data (mean and SD) for each included study were collected. Review Manager (RevMan) was used to manage the data. Meta-analysis was not considered appropriate due to the heterogeneity of the included studies. The results were presented as a narrative synthesis.

RESULTS

This review included 3869 participants from 32 RCTs and demonstrated a beneficial effect of psychological interventions for carers. Psychoeducation was widely used and the most evaluated intervention for carers.

CONCLUSIONS

Psychological interventions for carers are beneficial in helping to reduce negative outcomes and enhance positive outcomes. Future research could focus on exploring the impact of interventions on less evaluated outcomes such as depressive and anxiety symptoms.

PROSPERO REGISTRATION NUMBER

CRD42021233181.

Family-based interventions versus standard care for people with schizophrenia

BACKGROUND

People with schizophrenia often experience long-term psychosocial disabilities and frequent relapse. Family plays a key role in caring for ill relatives, which in turn probably contributes to high levels of distress and burdens for the family. Family-based interventions have been developed and applied to family members and their relatives with schizophrenia to improve their outcomes. This is an update of a Cochrane review that was last updated in 2011, which has been split into this review, one on group- versus individual-based family interventions and one on family-based cognitive versus behavioural management interventions.

OBJECTIVES

To assess the effects of family-based interventions for people with schizophrenia or schizophrenia-like disorders and their families compared with standard care.

SEARCH METHODS

We searched the following electronic databases from inception until April 2023: CENTRAL, Medline, Embase, PsycInfo, CINAHL, WHO International Clinical Trials Registry Platform (ICTRP), Clinicaltrials.gov, SinoMed, China Network Knowledge Infrastructure (CNKI), Wanfang, and Chinese Scientific Journals Database (VIP). We also searched the reference lists of included studies and accessible reviews for additional references.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared the effects of family-based interventions for people with schizophrenia or schizophrenia-like disorders and their families and reported at least one patient's and one family member's outcomes. In this update, we only investigated standard care as the comparator.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. The review authors independently screened studies, extracted data, and assessed risk of bias for each study using the Cochrane risk of bias tool for RCTs. We pooled data and estimated effects with the mean difference (MD), standardised mean difference (SMD), or risk ratio (RR) with 95% confidence interval (CI). We judged the certainty of evidence using GRADEpro GDT. We divided the outcomes into short-term (≤ 1 month postintervention), medium-term (> 1 to 6 months postintervention), and long-term follow-up (> 6 months postintervention), if available.

MAIN RESULTS

We identified 26 RCTs in this review, with 1985 people with schizophrenia or schizophrenia-like disorders, and 2056 family members. Most family-based interventions were conducted on a weekly or biweekly basis, with duration ranging from five weeks to two years. We had substantial concerns regarding the methodological quality of the included studies given that we judged all studies at high risk of performance bias and several studies at high risk of detection, attrition or reporting bias. Low-certainty evidence indicated that family-based interventions may reduce patients' relapse at one month or less postintervention (RR 0.66, 95% CI 0.49 to 0.89; 4 RCTs, 229 participants). We downgraded the evidence by two levels due to imprecision (small number of participants) and high risk of performance, detection and attrition bias. Compared to standard care, family-based interventions probably reduce caregiver burden at one month or less postintervention (MD -5.84, 95% CI -6.77 to -4.92; 8 RCTs, 563 participants; moderate-certainty evidence) and may result in more family members shifting from high to low expressed emotion (RR 3.90, 95% CI 1.11 to 13.71; 2 RCTs, 72 participants; low-certainty evidence). Family interventions may result in little to no difference in patients' death (RR 0.48, 95% CI 0.18 to 1.32; 6 RCTs, 304 participants; low-certainty evidence) and hospital admission (≤ 1 month postintervention; RR 0.81, 95% CI 0.51 to 1.29; 2 RCTs, 153 participants; low-certainty evidence) in comparison with standard care. Due to the heterogeneous measures and various follow-up periods, we were unable to provide pooled effect estimates for patients' compliance with medication and quality of life. We were very uncertain whether family interventions resulted in enhanced compliance with medication and improved quality of life for patients. We downgraded the evidence to very low certainty due to high risk of bias across studies, inconsistency (different directions of effects across studies), and imprecision (small number of participants or CIs of most studies including the possibility of no effect).

AUTHORS' CONCLUSIONS

This review synthesised the latest evidence on family interventions versus standard care for people with schizophrenia or schizophrenia-like disorders and their families. This review suggests that family interventions might improve patients' outcomes (e.g. relapse) and families' outcomes (e.g. caregiver burden and expressed emotion), with little to no difference in patients' hospital admission and adverse effects in terms of death. However, evidence on patients' compliance with medication and quality of life was very uncertain. Overall, the evidence was of moderate to very low certainty. Future large and well-designed RCTs are needed to provide more reliable evaluation of effects of family interventions in people with schizophrenia or schizophrenia-like disorders and their families.

Effectiveness of family interventions for patients with schizophrenia: A systematic review and meta-analysis

The family is the primary caregiver for most patients with schizophrenia, and their roles are essential in patients' illness trajectories and outcomes. Due to this, various family interventions for schizophrenia have been developed and applied to the relatives who take care of their family members with schizophrenia. This study examined the effectiveness of existing family interventions for schizophrenia in achieving their target outcomes at both the family and patient levels by utilizing a systematic review and meta-analysis. Combinations of terms were used to search for relevant studies from the databases. Thirty-seven randomized controlled trials that met the inclusion criteria were included in the analysis. Based on the pooled result of the included studies, the programmes significantly improved the targeted outcomes with large effect size. The programmes' impacts on family-related outcomes were higher than those on patients. Among the targeted outcomes, patients' treatment satisfaction and adherence and family caregivers' mental health were the most remarkable outcomes that had improved from the included programmes. Conversely, outcomes related to family relationships, caregiving experiences, perceived social support of family caregivers, and patients' medication use did not see significant improvements. The programmes delivered to individual family units and only to the family caregivers were more effective than those delivered to groups of caregivers and caregivers and patients together, respectively. Programme-focused interventions were more effective than emotion-focused ones. Based on these findings, an in-home visiting nurse programme or advanced technology is suggested when applying family interventions for schizophrenia in practice.

Comparison of stigmatizing views towards COVID-19 and mental disorders among adolescent and young adult students in China

Objective

Infectious diseases including COVID-19 and mental disorders are two of the most common health conditions associated with stigma. However, the comparative stigma of these two conditions has received less attention in research. This study aimed to compare the prevalence of stigmatizing views toward people with COVID-19 and mental disorders and the factors associated with these views, among a large sample of adolescent and young adult students in China.

Methods

A total of 9,749 adolescents and young adults aged 15-24 years completed a survey on stigmatizing attitudes toward COVID-19 and mental disorders, as well as mental health-related factors, including general mental health status and symptoms of depression, anxiety, insomnia, and post-traumatic stress disorder (PTSD). Multivariable linear regression analyses were conducted to identify factors associated with stigmatizing views.

Findings

The prevalence of COVID-19 and mental disorders-related stigma was 17.2% and 40.7%, respectively. COVID-19-related stigma scores were significantly higher among male students (β = 0.025, p < 0.05), those without quarantine experience (β = 0.035, p < 0.001), those with lower educational level (p < 0.001), those with lower family income (p < 0.01), and those with higher PTSD symptoms (β = 0.045, p < 0.05). Mental disorder-related stigma scores were significantly higher among individuals with average and lower-than-average levels of family income (p < 0.01), depression symptoms (β = 0.056, p < 0.001), anxiety symptoms (β = 0.051, p < 0.001), and mental health problems (β = 0.027, p < 0.05).

Conclusion

The stigma of mental disorders is higher in the youth population than the stigma of COVID-19. Factors associated with stigmatizing attitudes toward people with COVID-19 and mental disorders varied across the youth. Stigma-reduction interventions among the youth should be targeted specifically to COVID-19 or mental disorders conditions.

Affiliate stigma and caregiving burden among family caregivers of persons with schizophrenia in rural China

BACKGROUND

Although stigma and caregiving burden are important in relation to mental health recovery, few studies have been conducted on affiliate stigma and caregiving burden among family caregivers of persons with schizophrenia (FCPWS) in rural China.

AIMS

This study aimed to examine the severity level of affiliate stigma and caregiving burden, and identify the correlates among FCPWS in rural China.

METHODS

A mental health survey was conducted (N = 253 FCPWS) in Xinjin county, Sichuan province, China. Affiliate Self-Stigma Scale and Zarit Burden Interview Short Form were used. The regression analysis was performed to explore the correlates of stigma and burden.

RESULTS

Most FCPWS reported experiencing high and severe level of affiliate stigma (78.66%) and caregiving burden (95.26%). Family caregivers who were middle aged, unemployed, with high caregiving burden and low quality of life (QoL), showed more severe affiliate stigma. Family caregivers who were female, older, with low income, high affiliate stigma and low QoL, experienced greater caregiving burden.

CONCLUSIONS

The large majority of FCPWS in rural China experienced severe affiliate stigma, caregiving burden and poor QoL. It is crucial to develop culture-specific anti-stigma interventions to reduce caregivers' stigma and caregiving burden, and improve QoL. Specific risk factors of family caregivers' affiliate stigma and caregiving burden should be considered for development of health policy and community-based mental health services.