Family interventions for schizophrenia

Expressed emotion in the therapeutic relationship with schizophrenic patients

Patterns of interaction and attitudes in the relationships of 21 young schizophrenic patients, their parents and therapists were explored and compared with each other in this pilot study. The focus was on expressed emotion (EE), which was revealed to have an important impact on the course of the illness. In this study, the EE status of the relatives as well as of the therapists was rated using the five-minute speech sample method. Furthermore, data on the quality of interaction of therapists and parents with the patients were derived from the therapist/relative-patient interaction scale. Results showed that one-third of both the therapists and the parents were rated high on EE. High-EE relatives were rejected and perceived as inscrutable by the patients. The assessment of the therapeutic and familial relationships demonstrated the patients’ need for unequivocal communication. Differences and similarities in the interaction styles, and their implications for research and therapy are discussed.

New challenges in family interventions for schizophrenia

This review first outlines the rationale and research base supporting the development of family interventions for schizophrenia. The over-riding principles guiding effective family interventions for schizophrenia are then presented, along with the key components (engagement, assessment, education, communication skills training and problem-solving) shared by most family programs in schizophrenia. Meta-analyses demonstrating the efficacy of family interventions in reducing relapse and rehospitalization in schizophrenia are then discussed, along with issues regarding minimal duration of effective treatment, differential benefits of single and multiple family modalities and mixed evidence for the maintenance of treatment effects after termination. The benefits of participation in family-organized, nonprofessional support and education programs are then described. Finally, three issues meriting further study are outlined.

Training to recognise the early signs of recurrence in schizophrenia

BACKGROUND

Schizophrenia has a lifetime prevalence of less than one per cent. Studies have indicated that early symptoms that are idiosyncratic to the person with schizophrenia (early warning signs) often precede acute psychotic relapse. Early warning signs interventions propose that learning to detect and manage early warning signs of impending relapse might prevent or delay acute psychotic relapse.

OBJECTIVES

To compare the effectiveness of early warning signs interventions plus treatment as usual involving and not involving a psychological therapy on time to relapse, hospitalisation, functioning, negative and positive symptomatology.

SEARCH METHODS

Search databases included the Cochrane Schizophrenia Group Trials Register (July 2007 and May 2012) which is based on regular searches of BIOSIS, CENTRAL, CINAHL, EMBASE, MEDLINE and PsycINFO. References of all identified studies were reviewed for inclusion. We inspected the UK National Research Registe and contacted relevant pharmaceutical companies and authors of trials for additional information.

SELECTION CRITERIA

We included all randomised clinical trials (RCTs) comparing early warning signs interventions plus treatment as usual to treatment as usual for people with schizophrenia or other non-affective psychosis

DATA COLLECTION AND ANALYSIS

We assessed included studies for quality and extracted data. If more than 50% of participants were lost to follow-up, the study was excluded. For binary outcomes, we calculated standard estimates of risk ratio (RR) and the corresponding 95% confidence intervals (CI), for continuous outcomes, we calculated mean differences (MD) with standard errors estimated, and for time to event outcomes we calculated Cox proportional hazards ratios (HRs) and associated 95 % CI. We assessed risk of bias for included studies and assessed overall study quality using the GRADE approach.

MAIN RESULTS

Thirty-two RCTs and two cluster-RCTs that randomised 3554 people satisfied criteria for inclusion. Only one study examined the effects of early warning signs interventions without additional psychological interventions, and many of the outcomes for this review were not reported or poorly-reported. Significantly fewer people relapsed with early warning signs interventions than with usual care (23% versus 43%; RR 0.53, 95% CI 0.36 to 0.79; 15 RCTs, 1502 participants; very low quality evidence). Time to relapse did not significantly differ between intervention groups (6 RCTs, 550 participants; very low quality evidence). Risk of re-hospitalisation was significantly lower with early warning signs interventions compared to usual care (19% versus 39%; RR 0.48, 95% CI 0.35 to 0.66; 15 RCTS, 1457 participants; very low quality evidence). Time to re-hospitalisation did not significantly differ between intervention groups (6 RCTs; 1149 participants; very low quality evidence). Participants' satisfaction with care and economic costs were inconclusive because of a lack of evidence.

AUTHORS' CONCLUSIONS

This review indicates that early warning signs interventions may have a positive effect on the proportions of people re-hospitalised and on rates of relapse, but not on time to recurrence. However, the overall quality of the evidence was very low, indicating that we do not know if early warning signs interventions will have similar effects outside trials and that it is very likely that further research will alter these estimates. Moreover, the early warning signs interventions were used along side other psychological interventions, and we do not know if they would be effective on their own. They may be cost-effective due to reduced hospitalisation and relapse rates, but before mental health services consider routinely providing psychological interventions involving the early recognition and prompt management of early warning signs to adults with schizophrenia, further research is required to provide evidence of high or moderate quality regarding the efficacy of early warning signs interventions added to usual care without additional psychological interventions, or to clarify the kinds of additional psychological interventions that might aid its efficacy. Future RCTs should be adequately-powered, and designed to minimise the risk of bias and be transparently reported. They should also systematically evaluate resource costs and resource use, alongside efficacy outcomes and other outcomes that are important to people with serious mental illness and their carers.

Psychoeducation and the family burden in schizophrenia: a randomized controlled trial

BACKGROUND

The majority of patients with schizophrenia live with their relatives in Pakistan, thereby families experience a considerable burden. We aimed to study the impact of psychoeducation on the burden of schizophrenia on the family in a randomised controlled trial.

METHODS

A total of 108 patients with schizophrenia and their family members from the outpatient department of a teaching hospital in Lahore, Pakistan were randomised. Both groups received psychotropic drugs but one group received psychoeducation in addition. Family burden was assessed at the time of recruitment and at 6 months post intervention.

RESULTS

In all, 99 patients and their relatives completed the treatment. There was significant reduction in burden at post-intervention assessment in the psychoeducation group based on intention to treat analysis.

CONCLUSION

Family psychoeducation can be an important intervention for patients with schizophrenia in Pakistan.

The potential impact of the recovery movement on family interventions for schizophrenia: opportunities and obstacles

Many types of family interventions have been found to be effective in reducing exacerbations in schizophrenia; some also improve consumer social functioning and reduce family burden. Regardless of their origins, these interventions share a number of common features, such as showing empathy for all participants, providing knowledge about the illness, assuming a nonpathologizing stance, and teaching communication and problem-solving skills. Importantly, these family interventions have many characteristics that are consistent with the growing recovery movement in mental health in that they are community-based, emphasize achieving personally relevant goals, work on instilling hope, and focus on improving natural supports. Nevertheless, these interventions are generally reflective of older models of serious and persisting psychiatric illnesses that are grounded in a "patient being treated for a chronic illness" rather than a "consumer assuming as much responsibility as possible for his/her recovery" stance. These interventions could be made more consistent with recovery principles by (1) expanding the definition of family to include marital, parenting, and sibling relationships, (2) identifying better ways to match consumers with treatments, (3) broadening the research focus to include systems change that promotes making family members a part of the treatment team (with the consumer's consent), and (4) overcoming implementation obstacles that preclude access to effective family interventions for most consumers and their relatives.

Cognitive behavioural therapy (CBT) for carers of patients with Parkinson's disease: a preliminary randomised controlled trial

OBJECTIVE

Most individuals with Parkinson's disease live in their own homes cared for by a family member. Providing such long term care can be a source of significant stress, with many carers experiencing sleep difficulty, depression, anxiety, loneliness, and other symptoms of psychological strain. Cognitive behavioural therapy (CBT) is one of the most widely used psychological treatments in clinical use today, with applications across the full range of clinical conditions. It has been previously used in the management of other carer groups. The present study sought to evaluate the efficacy of CBT in treating psychological distress in a group of Parkinson's disease carers.

METHOD

A total of 30 carers scoring at caseness level on the 28 item General Health Questionnaire (GHQ-28) were randomised to receive either a course of 12-14 sessions of CBT or to a no-treatment control group.

RESULTS

Although some change was observed in both groups, significantly greater improvement on the GHQ-28 was observed after three months in the CBT treated group. Similar findings were observed in measures of caregiver strain and subjective burden, with the benefits being maintained over a subsequent three month follow up period.

CONCLUSIONS

These results offer preliminary support to the value of a CBT approach in the management of psychological morbidity in Parkinson's disease carers. Further larger scale research is needed in the future to examine the generalisability of the findings to a broader range of carers, assess the longer term impact on outcome in carers and those with Parkinson's disease, and explore how CBT can be best delivered in the most cost effective manner.

Affective reactivity of symptoms as a process discriminator in schizophrenia

Evidence from naturalistic and laboratory studies indicates that schizophrenic symptoms are exacerbated by stress or arousal of negative affect in some patients and not in others. Affective reactivity of symptoms may reflect a pathophysiological process or set of processes present only in a subset of cases of schizophrenia and, therefore, may constitute a dimension potentially relevant to subtyping efforts aimed at discriminating separate processes within the disorder. This paper reviews the evidence a) that affective reactivity of symptoms exists in some but not all schizophrenic patients, b) that this dimension corresponds with other variables that also are putative process discriminators, and c) that it is associated with a more global pathological reactivity to sensory and affective stimuli. Hypotheses as to its biological substrata, relevance to treatment, and importance to larger diagnostic issues are discussed.

A psychoeducational group intervention for family members of persons with HIV/AIDS

We describe a psychoeducational group intervention for family members of persons living with AIDS. The 33 family members were compared with 13 waiting-list controls in order to evaluate the effectiveness of the intervention. We focus on the practice aspects of the intervention, its development and implementation, and our belief that it is an apparently effective approach for helping family members work through the social and emotional aspects of the devastating impact of HIV/AIDS.

Behavioural family management in schizophrenia. Outcome of a clinic-based intervention

To test further the highly successful outcomes of a controlled study of in-home behavioural family management (BFM) for schizophrenic patients, a clinic-based version of this intervention was compared with customary care alone for 41 schizophrenic patients in a Veterans Administration (VA) mental health clinic. Monthly Brief Psychiatric Rating Scale (BPRS) ratings, conducted by clinic psychiatrists who were 'blind' to the patients' assignment, revealed that 3 (14%) patients who received behavioural family management as well as customary care, as compared with 11 (55%) patients who received customary care alone, had symptomatic exacerbations during the first year of treatment.

An assessment of the educational needs of chronic psychiatric patients and their relatives

Both psychiatric patients and their relatives benefit from learning about mental illness and how to cope with it, but the specific interests of these consumers remain unclear. To determine specific educational needs and to compare the needs of different consumers, a questionnaire survey was conducted with a sample of patients with schizophrenia and affective disorder and their relatives. Both patients and relatives reported strong interest in learning more about psychiatric illness and strategies for coping with common problems, but patients with schizophrenia were less interested than patients with affective disorder and both sets of relatives. Discriminant analyses revealed that needs differed as a function of patient diagnosis, patient/relative status, and relatives' membership of a self-help and advocacy organisation. Consumers of mental health services are capable of specifying their own educational needs, and educational programmes should be tailored to meet these.

Some aspects of family interventions in schizophrenia. II: Financial considerations

The direct costs to the mental health services for patients who participated in a trial of a behavioural family intervention to reduce schizophrenic relapse were estimated. Comparisons were made between two patient groups from households of high expressed emotion (HEE): one group received a nine-month family intervention (HEE Intervention) and the other group routine treatment (HEE Control). A third group consisted of patients from low-EE households (LEE Control). The significant decrease in relapse rates in the HEE Intervention group compared with the HEE Control group has previously been reported; the analysis of costs indicates that any increase in costs due to the family intervention is outweighed by a decrease in usage of the established mental health services. The intervention resulted in a decrease of 27% in mean cost per patient.

Teaching conflict resolution skills to the chronically mentally Ill. Social skills training groups for briefly hospitalized patients

Previous research on social skills training has demonstrated its usefulness as an adjunct treatment for a variety of psychiatric disorders. At the Medical College of Pennsylvania at Eastern Pennsylvania Psychiatric Institute, an acute-care psychiatric hospital, a social skills training group has been in operation for over 3 years. The group is unique in its format in several ways that are described in this article. Data collected over the 3-year period are also presented. The major findings indicate that even over a very brief period of time during an acute hospitalization, patients can learn basic conflict resolution skills. Some predictors of skill acquisition were also identified.

Process analysis in behavioral family therapy

Process research in behavioral family therapy (BFT) is a hitherto neglected area with the notable exception of the work of Alexander and Patterson with their colleagues. However, the development of instruments to assess therapist's behavior during the treatment session seems timely for the following reasons: (a) to investigate the relationship between therapist behavior and outcome, (b) to improve therapist training/supervision, (c) to establish treatment integrity in comparative outcome studies, and (d) to monitor treatment progress. For these purposes two sets of instruments were developed: (a) a category system to describe the content of a session, which is rated every 30 seconds and (b) several rating scales to evaluate therapist behavior, including relationship competency, ability to structure a session, didactic competence, ability to initiate behavioral probes, use of appropriate intervention strategies, use of reinforcement, and dealing with uncooperativeness. Scales are described, and data on their reliability and utility are presented.