Key Elements of a Family Intervention for Schizophrenia: A Qualitative Analysis of an RCT

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.

Family Empowerment Strategies for Relapse Prevention in Individuals With Schizophrenia: A Scoping Review

The current scoping review aimed to provide an overview of family empowerment strategies used in relapse prevention among individuals with schizophrenia. Three major topics were explored: (a) the family empowerment model used in relapse prevention among individuals with schizophrenia; (b) family intervention strategies; and (c) special considerations for integrating family empowerment in relapse prevention among individuals with schizophrenia. There is a need to identify and use family resources and strengths, such as acceptance of schizophrenia, development of spirituality, involvement in daily activities, and understanding of behaviors that exacerbate symptoms, to reduce relapse risk. The family empowerment paradigm incorporates new information and coping skills, family support, meaning-making, life objectives, self-reflection, and good family experiences. Families as agents of care at home should be provided with stress management and family psychoeducation to improve family resilience. Further research is needed to understand family empowerment and develop comprehensive guidelines regarding relapse prevention management among individuals with schizophrenia. [Journal of Psychosocial Nursing and Mental Health Services, 62(5), 19-27.].

Effectiveness of an Integrative Empowerment Intervention for Families on Caring and Prevention of Relapse in Schizophrenia Patients

Introduction

Patients with schizophrenia require extended treatment and recovery, leaving their families and support systems feeling helpless. Integrative empowerment is a strategy that utilizes outside-in and inside-out empowerment to increase the ability of families to care for their loved ones and prevent relapse.

Objective

This study aimed to investigate the impact of integrative empowerment intervention on enhancing the family's ability to care for and prevent relapse in patients with schizophrenia.

Methods

The study employed a quasi-experimental with a pre-test and post-test control group design. The research sample was comprised of 70 individuals from nuclear families residing in Semarang, all of whom were responsible for the care of individuals with schizophrenia. The participants were divided into two groups: the treatment group, consisting of 35 individuals, and the control group, also comprising 35 individuals. Participant selection was carried out using purposive sampling. Module and booklet were produced as an intervention tools. The integrative empowerment intervention program spanned a period of 5 weeks, involving one session per week, each lasting approximately 60-90 min. Data analysis was conducted through the utilization of the Wilcoxon and Mann-Whitney tests. The significance level for the study was set at p<.05.

Results

There was a significant change in the family's ability to care for patients with schizophrenia before and after the integrative empowerment intervention (p<.001), while there was no change in the control group's ability to care for patients with schizophrenia (p>.05). Integrative empowerment had a significant impact on increasing the family's ability to care for and prevent relapse in patients with schizophrenia (p<.001).

Conclusions

Nurses can help families strengthen their positive caregiving experiences through the home visit program by utilizing integrative empowerment. This study's findings highlight the importance of integrative empowerment in enhancing the family's ability to care for and prevent relapse in patients with schizophrenia.

Development of an integrative empowerment model to care for patients with schizophrenia disorder

Background

The main factor that causes a family the inability to care for patients with schizophrenia disorder is inadequate family-centered empowerment. Nevertheless, the family-integrated empowerment model has not been developed yet. This study aims to develop a integrative empowerment model to care for patients with schizophrenia disorder.

Design and methods

The mixed methods research design was divided into two stages. The first stage used a cross-sectional method with a questionnaire to 135 families who cared for patients with schizophrenia disorder using purposive sampling. Data analysis was obtained using Partial Least Squares (PLS). The second stage is a focused group discussion (FGD) conducted with six families, seven health workers, and six social workers, and discussions with two experts for model development.

Results

The integrative empowerment-based family empowerment model is developed from Outside-in empowerment (path coefficient = 0.309; t = 3.292) and Inside-out empowerment (path coefficient = 0.478; t = 4.850). Family factors is the most potent variable in shaping Inside-out empowerment (path coefficient = 0.217; t = 2.309). Moreover, re-meaning of caregiving is the strongest indicator that builds the Inside-out empowerment variable (t = 42.643). The value of Q2 is 0.433 indicates that this model can be generalized, since 61% of family ability to provide care for schizophrenia patients.

Conclusions

Re-meaning of caregiving is the most potent indicator in shaping Inside-out empowerment, which is the strongest factor forming this model. Nurses assist families to be able to find activities that can generate positive meaning when caring for patients with schizophrenia disorder.

"The most important thing is that those closest to you, understand you": a nested qualitative study of persons with psychotic disorders' experiences with family involvement

Introduction

Family interventions constitute effective treatment for persons with psychotic disorders. However, the active ingredients and beneficial processes of these interventions are insufficiently examined, and qualitative explorations of patients` experiences are lacking. This study was nested in a cluster randomised trial that implemented national guidelines on family involvement in Norwegian community mental health centres, including family psychoeducation and basic family involvement and support. The aim of this sub-study was to explore how patients with psychotic disorders experience systematic family involvement, and its significance.

Methods

We conducted semi-structured, individual interviews with 13 persons with a psychotic disorder after systematic family involvement. The participants were recruited through purposive sampling. Qualitative content analysis guided the analysis.

Results

Participants reported overall positive experiences with systematic family involvement. It was significant that the relatives increasingly understood more about psychosis and their situation, while they themselves also gained more insight into the relatives` situation. The participants emphasised the need to enable both patients and relatives to safely share experiences in a containing space, led by professionals. Shared understanding and awareness of each other's situation further improved communication, coping with the illness, reduced stress, and stimulated a more caring family environment. The therapist seemed crucial to facilitate these beneficial communication processes, and also to provide continuous support to the relatives. Reported challenges included that the participants felt vulnerable in the initial phase, a need for tailored approaches, and too late start-up.

Conclusion

Findings from this study suggest that persons with psychotic disorders may benefit greatly from participating in systematic family involvement. This study also gives new insight into possible mediators of positive outcomes both for the patients and the relatives. Systematic family involvement should be implemented a standard approach in the early phase of the disease, using a step-wise and tailored process.

The effects of patient personality traits and family cohesion on the treatment delay for patients with first-episode schizophrenia spectrum disorder

AIM

The duration of untreated psychosis (DUP) is an important prognostic indicator of schizophrenia. We explored the effects of patient personality and family relationships on delayed schizophrenia treatment.

METHODS

We prospectively included data from 169 patients diagnosed with first-episode schizophrenia. Personality traits were investigated using the Big Five Inventory (BFI-10) and family relationship was assessed employing the Family Adaptability and Cohesion Evaluation Scale-III (FACES-III). We explored patient clinical characteristics using the Positive and Negative Syndrome Scale (PANSS) and the Social and Occupational Functioning Scale (SOFAS). The DUP was defined as the time between the first appearance of psychotic symptoms and commencement of adequate antipsychotic treatment. Subjects were divided into two groups by the 3-month median DUP cutoff.

RESULTS

The average and median DUPs were 12 and 3 months, respectively. A longer DUP was associated with older age, a higher PANSS score, and a lower SOFAS score. The frequency of suicide attempts tended to be higher in the delayed treatment group (P = .055). The delayed treatment group scored significantly higher in conscientiousness factor of the BFI-10 and scored significantly lower family cohesion and adaptability factors of the FACES-III. Logistic regression showed that a longer DUP was significantly associated with higher-level conscientiousness on the BFI-10 and poorer family cohesion on the FACES-III.

CONCLUSION

Treatment delay was associated with reduced family cohesion and higher patient conscientiousness, suggesting that the family plays a crucial role in terms of patient access to mental health services when early psychotic symptoms appear.