Medical cost analysis of family psychoeducation for schizophrenia

Assessing a WeChat-Based Integrative Family Intervention (WIFI) for Schizophrenia: Protocol for a Stepped-Wedge Cluster Randomized Trial

BACKGROUND

Schizophrenia is a persistent and debilitating mental illness, and its prognosis depends largely on supportive care and systematic treatment. In developing countries like China, families constitute the major caregiving force for schizophrenia and are faced with many challenges, such as lack of knowledge, skills, and resources. The approach to support family caregiving in an accessible, affordable, feasible, and cost-effective way remains unclear. The wide-spread use of WeChat provides a promising and cost-effective medium for support.

OBJECTIVE

We aim to present a protocol for assessing a WeChat-based integrative family intervention (WIFI) to support family caregiving for schizophrenia.

METHODS

We will develop a WIFI program that includes the following three core components: (1) psychoeducation (WeChat official account), (2) peer support (WeChat chat group), and (3) professional support (WeChat video chat). A rigorous stepped-wedge cluster randomized trial will be used to evaluate the implementation, effectiveness, and cost of the WIFI program. The WIFI program will be implemented in 12 communities affiliated with Changsha Psychiatric Hospital through the free medicine delivery process in the 686 Program. The 12 communities will be randomized to one of four fixed sequences every 2 months during an 8-month intervention period in four clusters of three communities each. Outcomes will be assessed for both family caregivers and people with schizophrenia. Family caregivers will be assessed for their knowledge and skills about caregiving, social support, coping, perceived stigma, caregiver burden, family functioning, positive feelings, and psychological distress. People with schizophrenia will be assessed for their symptoms, functioning, quality of life, recovery, and rehospitalization. Cost data, such as intervention costs, health care utilization costs, and costs associated with lost productivity, will be collected. Moreover, we will collect process data, including fidelity and quality of program implementation, as well as user attitude data. Treatment effects will be estimated using generalized linear maximum likelihood mixed modeling with clusters as a random effect and time as a fixed effect. Cost-effectiveness analysis will be performed from the societal perspective using incremental cost-effectiveness ratios. Qualitative analysis will use the grounded theory approach and immersion-crystallization process.

RESULTS

The study was funded in August 2018 and approved by the institutional review board on January 15, 2019. Preliminary baseline data collection was conducted in May 2019 and completed in September 2019. The WIFI program is expected to start in September 2020.

CONCLUSIONS

This is the first study to assess a WeChat-based mHealth intervention to support family caregiving for schizophrenia in China. The innovative study will contribute to the development of a more cost-effective and evidence-based family management model in the community for people with schizophrenia, and the approach could potentially be integrated into national policy and adapted for use in other populations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04393896; https://clinicaltrials.gov/ct2/show/NCT04393896.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/18538.

Family Interventions for Schizophrenia and the Psychoses: A Review

Family psychoeducation as a treatment for schizophrenia was developed 40 years ago almost simultaneously and independently by investigators who at the time were not family therapists. Although the original goal was to decrease high expressed emotion as a means of preventing relapse, later variations have gone beyond to focus on social and role functioning and family well-being. Explicitly disavowing the earlier assumptions that family pathology caused relapse and deterioration, family psychoeducation seeks to engage family members as more sophisticated partners, complementing interventions by clinicians with specialized interactions and coping skills that counter the neurologic deficits inherent to the disorder. It has proved to be one of the most consistently effective treatments available. Reports on outcome studies now number more than 100, while meta-analyses put relapse rate reduction at 50-60% over treatment as usual. The most recent application in first episode and prodromal psychosis, combined with other evidence-based interventions, is yielding perhaps the most promising results yet achieved-substantial return of functioning and avoidance of psychosis altogether. Reviewed here are its scientific, theoretical, and clinical sources, a description of the most commonly applied version-the multifamily group format, selected clinical trials spanning those four decades, international and ethnic adaptations, and studies on mechanisms of efficacy.

A review on schizophrenia and relapse--a quest for user-friendly psychopharmacotherapy

OBJECTIVE

Schizophrenia in general is notoriously associated with relapses rendering the illness progressive to worse outcomes, a concept of which is compatible with neurotoxicity. Therefore, relapse prevention is of utmost clinical relevance.

METHODS

In this review, we aim to put relapse into clinical context in the realm of natural history of, or heterogeneity in, schizophrenia and summarize risk factors of relapse. We discuss how to effectively 'define' relapse in schizophrenia and recent meta-analytic studies on this topic to highlight the importance of continuous antipsychotic treatment.

RESULTS

The following issues emerged: 'How low maintenance antipsychotic dosage could be?’, 'How extended dosing could be?’, 'Who could be successfully withdrawn from antipsychotics?’ and 'How relapse could be defined in the first place?’ The question in particular is how better to deliver antipsychotics at the lowest possible, whereby dose and dosing interval are relevant. While ongoing antipsychotic treatment is the rule, recent works are pointing to a possibility of lower dosage in the maintenance phase of the illness.

CONCLUSIONS

Bearing in mind that suboptimal adherence and withdrawal from antipsychotics are an established and unequivocal risk factor for relapse, further investigations are certainly needed to explore user-friendly manner of psychopharmacotherapy to prevent relapse in schizophrenia.

The effect psychoeducation intervention has on the caregiving burden of caregivers for schizophrenic patients in Turkey

This study was conducted to determine the effects psychoeducation given to caregivers of schizophrenic patients has on the level of care burdens. The model used was one group pre-test post-test pre-experimental model. It was conducted on 31 caregivers in psychiatry clinics between October 2007 and June 2008. Data were collected using the 'Zarit Caregiver Burden Scale' and the questionnaire form that determined the introductory features of caregivers. The study group participated in eight psychoeducation sessions. The average pre-test score of care burden for caregivers was 57.2 ± 9.9, and the average post-test score was 34.3 ± 9.9. The distinction between the average pre-test and post-test score of care burden for caregivers was significant (P = 0.001). Psychoeducation, given for caregivers of patients with schizophrenia, had a significant effect in decreasing individuals' caregiving burdens. Psychoeducation programmes directed at families should be considered as a therapeutic strategy for patients with schizophrenia.

A nonparametric statistical method that improves physician cost of care analysis

OBJECTIVE

To develop a compositing method that demonstrates improved performance compared with commonly used tests for statistical analysis of physician cost of care data.

DATA SOURCE

Commercial preferred provider organization (PPO) claims data for internists from a large metropolitan area.

STUDY DESIGN

We created a nonparametric composite performance metric that maintains risk adjustment using the Wilcoxon rank-sum (WRS) test. We compared the resulting algorithm to the parametric observed-to-expected ratio, with and without a statistical test, for stability of physician cost ratings among different outlier trimming methods and across two partially overlapping time periods.

PRINCIPAL FINDINGS

The WRS algorithm showed significantly greater within-physician stability among several typical outlier trimming and capping methods. The algorithm also showed significantly greater within-physician stability when the same physicians were analyzed across time periods.

CONCLUSIONS

The nonparametric algorithm described is a more robust and more stable methodology for evaluating physician cost of care than commonly used observed-to-expected ratio techniques. Use of such an algorithm can improve physician cost assessment for important current applications such as public reporting, pay for performance, and tiered benefit design.

Recent developments in family psychoeducation as an evidence-based practice

Among potential resources for people with serious mental illnesses (SMI) and their families, professionally delivered family psychoeducation (FPE) is designed to engage, inform, and educate family members, so that they can assist the person with SMI in managing their illness. In this article, we review research regarding FPE outcomes and implementation since 2001, updating the previous review in this journal (McFarlane, Dixon, Lukens, & Lucksted, Journal of Marital and Family Therapy 2003; 29, 223). Research on a range of FPE variations continues to return mostly positive effects for adults with schizophrenia and increasingly, bipolar disorder. More recent studies include functional outcomes as well as the more common relapse and hospitalization. FPE research involving adults with other diagnoses is increasing, as is FPE research outside the United States In both cases, uneven methodologies and multiple FPE variations make drawing conclusions difficult, although the core utility of access to information, skill building, problem solving, and social support often shines though. Since the previous review, several FPE programs for parents of children or youth with mood disorders have also been developed, with limited research showing more positive than null results. Similarly, we review the developing inquiry into early intervention and FPE, short-form FPE, and cost studies involving FPE. The second half of the article updates the paradox of FPE's evidence base versus its persistently low use, via recent implementation efforts. Multiple challenges and facilitating factors across healthcare systems and financing, individual programs and providers, family members, and consumers shape this issue, and we conclude with discussion of the need for empirical evaluation of implementation strategies and models.

Psychoeducation in schizophrenia: new developments and approaches in the field

PURPOSE OF REVIEW

The aim of this review is to summarize the literature on psychoeducation in schizophrenia published during the past year; this literature shows that pragmatic approaches and new adaptations have been developed.

RECENT FINDINGS

The current literature indicates that studies on psychoeducation in schizophrenia in real-world settings show results comparable to those in experimental settings; brief psychoeducational interventions may have long-term effects on relapse and rehospitalization rates; and combining diagnoses may be helpful for new, short psychoeducational formats, but also for smaller hospitals with too few patients with the same diagnosis for group psychoeducation. Peer-to-peer education programs for families and patients have been developed, and culturally sensitive topics, the patients' perspective, quality-of-life issues and sex aspects were integrated into psychoeducation. A new meta-analysis on psychoeducation shows that there is a medium effect size for relapse and rehospitalization reduction if both the patient and the family participate.

SUMMARY

Up to the present, patient-directed approaches are much more frequent in clinical practice than bifocal psychoeducation. Therefore, future research must focus on patient-directed psychoeducation and, here especially, on integrating the more stable outpatients, who appear to profit more from psychoeducation than do symptomatic inpatients.