Interventions to improve the experience of caring for people with severe mental illness: systematic review and meta-analysis

Non-pharmacological interventions to improve mental health outcomes among female carers of people living with a neurological condition: a systematic review

PURPOSE

This systematic review aims to examine the effectiveness of non-pharmacological interventions for improving mental health outcomes among female carers of people living with a neurological condition.

MATERIALS AND METHODS

A narrative synthesis of English-language randomized controlled trials was undertaken.

RESULTS

18 unique studies were included. Intervention components that were found to have improved mental health outcomes were: delivered in person, to groups, on an intermittent schedule with ≥10 sessions; had a duration between 3-6 months; and were facilitated by research staff or allied health professionals. As the review had few robust studies, results of mental health outcomes reported in studies assessed as low risk of bias were highlighted in the review. Psychoeducation interventions, cognitive behavioural interventions, and support group interventions were found to improve depression. Psychoeducation interventions were also found to improve burden.

CONCLUSIONS

There is a clear need for adequately powered, high-quality randomised controlled trials to determine the effectiveness of non-pharmacological interventions for female carers of people living with a neurological condition.

Implementation of guidelines on Family Involvement for persons with Psychotic disorders: a pragmatic cluster randomized trial. Effect on relatives' outcomes and family interventions received

Background

Family interventions (FI) are recommended as part of the treatment for psychotic disorders, but the implementation in mental health services is generally poor. Recently, The Implementation of guidelines on Family Involvement for persons with Psychotic disorders (IFIP) trial, demonstrated significant improvements in implementation outcomes at cluster-level. This sub-study aims to examine the effectiveness of the IFIP intervention on relatives' outcomes and received FI.

Methods

A cluster randomized controlled trial, was conducted in 15 Norwegian Community Mental Health Center (CMHC) units that were randomized to either the IFIP intervention, including implementation interventions and clinical interventions, or treatment as usual (TAU). The clinical interventions consisted of FI: basic family involvement and support (BFIS) to all patients and family psychoeducation (FPE) to as many as possible. Patients with psychotic disorders and their closest relative were invited to fill in questionnaires at inclusion and 6 months and 12 months follow-up. Received FI was reported by both relatives and clinicians. The relatives' primary outcome was satisfaction with health service support, measured by the Carer well-being and support questionnaire part B (CWS-B). The relatives' secondary outcomes were caregiver experiences, expressed emotions and quality of life. Patients' outcomes will be reported elsewhere.

Results

In total 231 patient/relative pairs from the CMHC units were included (135 intervention; 96 control).The relatives in the intervention arm received an increased level of BFIS (p=.007) and FPE (p < 0.05) compared to the relatives in the control arm, including involvement in crisis planning. The primary outcome for relatives' satisfaction with health service support, showed a non-significant improvement (Cohen's d = 0.22, p = 0.08). Relatives experienced a significant reduced level of patient dependency (Cohen's d = -0.23, p = 0.03).

Conclusion

The increased support from clinicians throughout FI reduced the relatives' perceived level of patient dependency, and may have relieved the experience of responsibility and caregiver burden. The COVID-19 pandemic and the complex and pioneering study design have weakened the effectiveness of the IFIP intervention, underscoring possible potentials for further improvement in relatives' outcomes.

Clinical Trial Registration

ClinicalTrials.gov, identifier NCT03869177.

Experiences of support received by carers of people who are involuntarily admitted to hospital under the Mental Health Act: qualitative study of carers' perspectives

BACKGROUND

Carers of people who are involuntarily admitted to hospital report feeling isolated and unsupported by services. The Independent Review of the Mental Health Act (MHA) recommended that carers be supported. However, no research has directly explored what type of support carers would find most helpful when a relative/friend is involuntary admitted.

AIMS

To explore carers' experiences and views around the support they want to receive when their relative/friend is involuntarily admitted under the MHA.

METHOD

A total of 22 one-to-one interviews with carers were conducted online at three sites across England. Audio recordings of the interviews were transcribed, and data were analysed with thematic analysis.

RESULTS

Four main themes were identified: (a) heterogeneity in the current support for carers, (b) information about mental health and mental health services, (c) continuous support, and (d) peer support and guidance. Carers reported receiving support from professionals, peers and relatives, but this was unstructured, and the extent of support varied across carers. Carers reported wanting more information about mental health services, and for this information to be consistent. Carers also reported wanting emotional support from a single, continuous person, helping them establish a more personal and sincere connection. Peers were also identified as important in the provision of carer support, allowing carers to feel reassured and understood in their experience.

CONCLUSIONS

The support received by carers is currently unstructured. To meet the MHA review recommendations, carers of patients who are involuntarily admitted should be allocated a named contact person, ideally with lived experience, to offer information and personal continuity of support.

Individual placement and support: A qualitative investigation of carers' experiences supporting someone experiencing mental illness into employment

BACKGROUND

Unemployment rates for people living with mental illness remain persistently high. Individual Placement Support (IPS) is an evidence-based employment model that supports people with severe mental illness to gain employment. Although carers provide emotional and instrumental support for people with mental illness, there is limited research exploring carers' perspectives of IPS.

AIMS

To explore carers' perspectives of their experience as caregivers of individuals living with mental illness who have participated in IPS.

METHODS

This qualitative descriptive study gained carers' perspectives through semi-structured interviews. A convenience sample of eight carers was recruited via a community mental health service in Adelaide. Data were analysed thematically.

FINDINGS

Three main themes were identified: (1) employment benefits, (2) factors that may impact on employment, and (3) knowledge and opinions of IPS. Within each theme, four sub-themes emerged.

CONCLUSIONS

This study addresses a gap in research and provides insights into carers' experiences of IPS. Increased communication and involvement of carers in IPS may benefit IPS participants and staff as carers provide invaluable additional insight into supporting individuals through their employment journey.

Assessing the Educational Needs of Family Caregivers of Psychiatric Patients in Jeddah, Saudi Arabia

Background Family caregivers of psychiatric patients in Saudi Arabia and most of the Eastern world are suffering a big burden as a result of their caregiving role. Aim This study aims to assess the need for psychoeducation for family caregivers of psychiatric patients from outpatient clinics in a psychiatric hospital in Jeddah, Saudi Arabia. Materials and methods A cross-sectional descriptive-analytical study was conducted, which included a total of 379 family caregivers providing care to a patient suffering from a psychiatric illness. Results The majority of family caregivers looking after a patient suffering from a psychiatric illness were a brother or sister (20.8%), followed by a son or daughter (20.6%), and lastly, a spouse (10.3%). The top 10 important educational needs of the caregivers included their desire to know about the daily treatment of the patient, followed by how to improve social relationships, and a need for effective stress management. Family caregivers also showed interest in stress and illness. The caregivers' areas of least concern were about the admission of the patients to psychiatric hospitals, recent research on mental illnesses, and how to deal with weight gain. Conclusion The study showed that caregivers demonstrated a need for more experience in how to care for psychiatric patients. Indeed, this has an interrelated impact on the general well-being of both the patient and the caregiver. The study recommends the need for care guidelines to be provided by hospitals from the patient's education department for caregiving to help the family in their daily care.

Strategies to Alleviate the Burden Experienced by Informal Caregivers of Persons With Severe Mental Disorders in Low- and Middle-Income Countries: Scoping Review

BACKGROUND

There is considerable evidence of the burden of care encountered by informal caregivers of persons with severe and enduring mental health conditions in low- and middle-income countries. Previous studies have highlighted the need to support these informal caregivers as key players in the care of these patients. To date, limited evidence exists on the extent and types of strategies for supporting these informal caregivers in low- and middle-income countries.

OBJECTIVE

This scoping review aims to identify and describe the extent and type of evidence on the existing strategies for alleviating the burden of care among informal caregivers of persons with severe and enduring mental health conditions in low- and middle-income countries.

METHODS

A systematic literature search was completed following the Joanna Briggs Institute methodology for scoping reviews. The participants, concept, and context framework was used to guide the search for literature sources across 5 databases: PubMed, MEDLINE, CINAHL, and PsycINFO for published literature and ProQuest for unpublished literature. This review included studies that reported on strategies for alleviating the burden of care among informal caregivers of persons with severe and enduring mental health conditions, with a focus on studies that evaluated or recommended caregiver interventions and support strategies in low- and middle-income countries. The search was limited to studies conducted between 2001 and 2021, and only papers written in English were considered for inclusion. Using the Covidence software (Veritas Health Innovation), 2 reviewers independently screened the papers, applied the inclusion and exclusion criteria, and met biweekly to discuss and resolve conflicts. The relevant studies and reported outcomes were summarized, organized, and analyzed descriptively using numeric summary analysis and deductive content analysis.

RESULTS

Of the 18,342 studies identified, 44 (0.24%) met the inclusion criteria. The included studies were from 16 low- and middle-income countries in Asia, Africa, Europe, and South and North America. Most studies (21/44, 48%) were randomized controlled trials conducted in Asian countries. The identified strategies were grouped into 2 categories: implemented and recommended intervention strategies. Identified strategies included community-based interventions, psychoeducation interventions, support groups, cognitive behavioral therapy, spirituality-based interventions, and smartphone-based interventions. In addition, mindfulness and empowerment, collaborative interventions, standard care, financial and social support, counseling, occupation-based interventions, policy and legislature, and access to mental health care were identified. Psychoeducation and support group interventions were identified as common strategies for alleviating the burden of care among informal caregivers of persons with severe and enduring mental health conditions.

CONCLUSIONS

This review provides evidence on the types of implemented and recommended strategies for alleviating the burden of care among informal caregivers in low- and middle-income countries. Although psychoeducational interventions were the most preferred strategy for alleviating burden, their benefits were short-lived when compared with peer-led support groups.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/44268.

A mixed-methods evaluation of the impacts of an online Carer wellbeing and connection program

Objective

To evaluate a facilitated, 90-min session, delivered for four weeks, Online Carer Wellbeing and Connection Program in Victoria, Australia.

Methods

One hundred and three carers took part in the evaluation. Eighty-six completed both pre- and post-program surveys evaluating program impacts on psychological distress, perceived loneliness, and social support. Qualitative interviews were conducted (n = 76) post-program for experiential data.

Findings

Paired samples t-tests showed significant decreases between pre- and post-program for psychological distress (M = 25.10, SD = 7.08; M = 22.00, SD = 6.57; t(85) = 4.88, p = 0.000), perceived loneliness (M = 6.69, SD = 1.89; M = 6.14, SD = 1.76; t(85) = 3.45, p = 0.000) and perceived social support (M = 8.31, SD = 2.48; M = 8.83, SD = 2.21; t(85) = -2.54, p = 0.013). Thematic analysis identified positive experiences and the mechanisms of action (or the ingredients for program success) as: 1. Delivery by a trained facilitator; 2. Provision of respite for person being cared for during meetings; 3. Technical assistance; 4. Online modality; 5. Inclusivity; 6. Diversity of experience; 7. Shared understanding; 8. Safety; 9. Emotional release; 10. Reflection, and; 11. Self-care practices.

Innovation

A model illustrating the mechanisms of action based on the findings of the mixed-methods evaluation is presented to support wider implementation and translation.

Conclusion

The online program effectively reduced psychological distress and loneliness and improved carer wellbeing.

A randomized controlled trial of a targeted support program for informal caregivers in adult psychiatry

Background

The importance of informal caregivers for persons with severe mental illness has been demonstrated. However, this role may cause a high care burden that considerably affects caregiver health. The Ensemble program is a five-session brief individual intervention designed to support informal caregivers. This trial aimed to assess the efficacy of the program versus SAU (support as usual) for participants with a high care burden.

Methods

A single-center randomized controlled trial including 149 participants was conducted. Caregivers in the intervention arm participated in the Ensemble program. The effects of the intervention were assessed using mixed models for repeated measures analysis of variance on improvements in informal caregivers' psychological health status, optimism levels, burden scores, and quality of life at three time points (T0 = pretest; T1 = posttest at 2 months, and T2 = follow-up at 4 months).

Results

Analysis of the Global Psychological Index showed no significant effect at the two endpoints in favor of the Ensemble group. However, the Brief Symptom Inventory-Positive Symptom Distress Index was significantly lower at the two-month follow-up. A significant reduction in burden on the Zarit Burden Interview was observed post-intervention, along with an increase in optimism levels on the Life Orientation Test-Revised at follow-up in the Ensemble group. No significant differences were observed in quality of life. Clinical improvements in both psychological health status and burden levels were also identified.

Conclusion

The Ensemble program offers an inclusive approach based on a recovery perspective that significantly reduces symptom distress and burden and increases optimism among informal caregivers.Clinical trial registration: https://clinicaltrials.gov/, NCT04020497.

Psychosocial interventions for carers of people with severe mental and substance use disorders: a systematic review and meta-analysis

BACKGROUND

Severe mental disorders - such as schizophrenia, bipolar disorder, and substance use disorders - exert a negative impact not only on affected people but also on their carers. To support carers of people with severe mental disorders, several psychosocial interventions have been developed.

METHODS

This systematic review and meta-analysis aimed to assess whether psychosocial interventions for carers of persons with schizophrenia, bipolar disorder, or substance use disorders produce benefit/harm with respect to a series of outcomes - including subjective and objective burden, depressive symptoms, well-being/quality of life, sleep, skills/knowledge, self-efficacy, physical health - as compared to standard support/support as usual or other control conditions.

RESULTS

In carers of persons with schizophrenia, psychoeducational interventions were associated with significant improvement in personal burden, well-being, and knowledge about the illness; and a supportive-educational intervention with an improvement in personal burden. In carers of persons with bipolar disorder, psychoeducational interventions were associated with significant improvement in personal burden and depressive symptoms; family-led supportive interventions with an improvement in family burden; family-focused intervention and online "mi.spot" intervention with a significant reduction in depressive symptoms. Psychosocial interventions used for carers of persons with substance use disorders were found to be overall effective on the level of well-being, but the low number of trials did not allow detection of differences between the various psychosocial interventions.

CONCLUSIONS

The quality of the evidence ranged from very low to moderate, suggesting the need for further better-quality research.

Supporting carers to improve patient safety and maintain their well-being in transitions from mental health hospitals to the community: A prioritisation nominal group technique

INTRODUCTION

Carers of people with mental illness may face distinct challenges, including navigating fragmented health and social services during discharge from mental health hospitals. Currently, limited examples of interventions that support carers of people with mental illness in improving patient safety during transitions of care exist. We aimed to identify problems and solutions to inform future carer-led discharge interventions, which is imperative for ensuring patient safety and the well-being of carers.

METHODS

The nominal group technique was used which combines both qualitative and quantitative data collection methods in four distinct phases: (1) problem identification, (2) solution generation, (3) decision making and (4) prioritisation. The aim was to combine expertise from different stakeholder groups (patients, carers and academics with expertise in primary/secondary care, social care or public health) to identify problems and generate solutions.

RESULTS

Twenty-eight participants generated potential solutions that were grouped into four themes. The most acceptable solution for each was as follows: (1) 'Carer Involvement and Improving Carer Experience' a dedicated family liaison worker, (2) 'Patient Wellness and Education' adapting and implementing existing approaches to help implement the patient care plan, (3) 'Carer Wellness and Education' peer/social support interventions for carers and (4) 'Policy and System Improvements' understanding the co-ordination of care.

CONCLUSION

The stakeholder group concurred that the transition from mental health hospitals to the community is a distressing period, where patients and carers are particularly vulnerable to safety and well-being risks. We identified numerous feasible/acceptable solutions to enable carers to improve patient safety and maintain their own mental wellbeing.

PATIENT AND PUBLIC CONTRIBUTION

Patient and public contributors were represented in the workshop and the focus of the workshop was to identify the problems they faced and co-design potential solutions. Patient and public contributors were involved in the funding application and study design.

Improvements in Treatment Adherence after Family Psychoeducation in Patients Affected by Psychosis: Preliminary Findings

(1) Background: Family psychoeducation is a well-recognized intervention which aims to improve the outcomes of illness in patients affected by psychosis. It has benefits in treatment adherence and leads to a reduction in relapses, higher levels of patient insight, and lower levels of stress within the family and among caregivers. (2) Methods: Eight patients and their families were recruited and randomly assigned to a Falloon-based family psychoeducation (FPP) intervention, and nine patients and their families were randomized to a Gestalt-based family intervention (GT). We compared the outcomes of these two treatment groups at a baseline assessment (T0), at the end of the programs (T1), and 6 and 12 months after the end of the programs (T2 and T3). The assessments included examinations of cognition (The Mini-Mental State Examination (MMSE) and The Five Point Test (5 Point)), the psychopathology and severity of illness (The Brief Psychiatric Rating Scale (BPRS), The Positive and Negative Syndrome Scale (PANSS), and The Clinical Global Impression Scale (CGI)), expressed emotion in families (Expressed Emotionality (Family Questionnaire-EE)), patient quality of life (The World Health Organization Quality of Life-BREF (WHOQOL-B)), social functioning (The Personal Social Performance (SPS)), aggression (Modified Overt Aggression Scale (MOAS)), and treatment adherence (The Brief Medication Adherence Report Scale (BMARS)). The primary aim was to test whether the FFP vs. GT program was more effective in improving treatment adherence over time. (3) Results: treatment adherence improved much more in the FFP group over time at any follow-up: +43.1% at T1, +24.0% at T2, and +41.6% at T3. Other characteristics, including psychopathology and the clinical stability of the subject, did not change over time. (4) Discussion: Family psychoeducation based on the Falloon program was effective at improving treatment adherence and contributed to avoiding relapses in the long term. Further studies on larger samples should be conducted to confirm this evidence, and similar psychoeducational programs should be routinely promoted in the clinical setting.

Effectiveness of Psychoeducation on Burden among Family Caregivers of Adults with Schizophrenia: A Systematic Review and Meta-Analysis

Caring for relatives living with schizophrenia could lead to caregivers' burden. It is believed that lack of information and understanding about schizophrenia and lack of skills to cope effectively while caring for their adult relatives largely contribute to the burden they experience. The burden is assessed using assessment scales. This review aims to assess the effectiveness of psychoeducation in alleviating the burden experienced by family caregivers of adults living with schizophrenia and to identify essential factors that facilitate positive outcomes. Five databases (ASSIA, CINAHL, Embase, MEDLINE EBSCO, and PsycINFO) were systematically searched using combinations of the following key terms: "family caregivers," "schizophrenia," "burden," "psychoeducation," and "adults." Meta-analysis of included studies was conducted using RevMan 5.4. Five RCTs with 320 family caregivers were included in the review. Overall, none of the studies showed a low risk of bias. The evidence suggests that face-to-face group psychoeducation reduced family caregivers' burden when measured across different time points: one-week postintervention (mean difference -3.87 and Cl -6.06 to -1.70), six months (MD -8.76 and Cl -12.38 to -5.13), and twelve months (MD -7.38 and Cl -9.85 to -4.91). Measurements immediately after the intervention, one month, and three months postintervention when reported narratively also showed a reduction in family caregivers' burden. Face-to-face group psychoeducation provided for family caregivers effectively alleviates the burden they experience. Factors such as program content and teaching methods facilitated positive outcomes. It is recommended that psychoeducation should be integrated as a routine intervention for family caregivers.

An online survey to understand the needs of caregivers of family members with 22q11 deletion syndrome

BACKGROUND

Most individuals with 22q11.2 deletion syndrome (22q11DS) have multi-system and lifelong needs requiring substantial support. Their primary caregivers are usually family members who dedicate lifelong time and effort to their role. The pressures of their roles can negatively impact caregivers' psychosocial well-being, suggesting a need for additional support for this community who currently have no specialised interventions available.

METHOD

This online study surveyed 103 caregivers of family members with 22q11DS to determine the barriers to accessing support that they faced, the kind of support they would value and whether an online intervention could meet their needs.

RESULTS

The caregivers indicated that a brief online intervention focused on teaching practical skills and connecting them with a peer network of support would be most valuable.

CONCLUSIONS

Future studies are planned that will build on these results by designing and testing online interventions tailored to this community.

The Efficacy of Psychoeducational Family Intervention for Major Depression: Study Protocol of a Randomized Controlled Trial

This study aims to assess the efficacy of a psychoeducational family intervention (PFI) to reduce the severity of depressive symptoms and to improve psychosocial functioning and to increase social contacts in a sample of patients with major depressive disorder (MDD). The degree to which PFI will reduce patients' relapses, hospitalizations, and self-stigmatization and will improve their quality of life will also be assessed. Other secondary outcomes include the improvement of relatives' coping strategies, family burden, expressed emotions and quality of life. This non-profit, unfunded, national, multicentric randomized controlled trial with blinded outcome assessments will be carried out in 24 Italian university outpatient units. Families will be assessed at baseline and at 6, 12, and 24 months post-randomization. Our working hypothesis is that the PFIs will reduce the patients' severity of depressive symptoms, their relapses, and their hospitalizations, and that they will improve their psychosocial functioning and quality of life. We expect these results to be maintained after 12 and 24 months, albeit with a reduction in magnitude. The sample will consist of 384 patients randomized at a 1:1 ratio and stratified according to center, age, gender, and educational level.

Does the Nae Umeed group intervention improve mental health and social participation? A pre-post study in Uttarakhand, India

There are few evidence-based interventions to support caregiver mental health developed for low- and middle-income countries. Nae Umeed is a community-based group intervention developed with collaboratively with local community health workers in Uttarakhand, India primarily to promote mental wellbeing for caregivers and others. This pre-post study aimed to evaluate whether Nae Umeed improved mental health and social participation for people with mental distress, including caregivers. The intervention consisted of 14 structured group sessions facilitated by community health workers. Among 115 adult participants, 20% were caregivers and 80% were people with disability and other vulnerable community members; 62% had no formal education and 92% were female. Substantial and statistically significant improvements occurred in validated psychometric measures for mental health (12-Item General Health Questionnaire, Patient Health Questionnaire-9) and social participation (Participation Scale). Improvements occurred regardless of caregiver status. This intervention addressed mental health and social participation for marginalised groups that are typically without access to formal mental health care and findings suggest Nae Umeed improved mental health and social participation; however, a controlled community trial would be required to prove causation. Community-based group interventions are a promising approach to improving the mental health of vulnerable groups in South Asia.

Attitudes towards family involvement in nursing care among psychiatric nurses in Hong Kong: A cross-sectional descriptive study

WHAT IS KNOWN ON THE SUBJECT?: Family-involved interventions can result in better outcomes than traditional mental health care for both service users and their families. Nurses' attitudes towards family involvement can affect family participation in care. Earlier studies on psychiatric nurses' attitudes towards family involvement in care report ambiguous findings. Hong Kong's unique integrated cultures may influence Hong Kong psychiatric nurses' attitudes towards family involvement in nursing care. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The majority of psychiatric nurses had positive views on family involvement in care in Hong Kong. Four variables (i.e. gender, clinical experience, nature of working unit and family nursing training) of psychiatric nurses are associated with their attitudes towards family involvement in care in Hong Kong. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Policy makers should develop strategies to increase psychiatric nurses' awareness of the importance of family involvement in patient care. Nurse educators help to design family nursing training to enhance psychiatric nurses' competence in collaborating with families of people suffering from mental disorders.

ABSTRACT

INTRODUCTION: In Hong Kong, involving the family in nursing care is still optional and mainly depends on nurses' attitudes and the willingness of the family. Hong Kong psychiatric nurses' attitudes towards family involvement in nursing care may be influenced by the unique integrated Eastern and Western cultures, however earlier studies report ambiguous findings.

AIMS

This study aimed to assess Hong Kong psychiatric registered nurses' attitudes towards family involvement in care and its associated factors.

METHODS

This study is a cross-sectional descriptive online survey with convenience sampling based on the Families' Importance in Nursing Care-Nurses' Attitudes (FINC-NA) instrument.

RESULTS

Most of the psychiatric nurses had supportive attitudes towards family involvement in care. Females with more clinical experience, working in a rehabilitation-related unit and having attended a family nursing education course were associated with positive attitudes towards family involvement in care.

DISCUSSION

The supportive attitude of psychiatric nurses may be explained by the shift of mental health nursing care from hospital care to community care in recent decades.

IMPLICATIONS FOR PRACTICE

Mental health nurse education and training in Hong Kong could place more emphasis on building family work skills, particularly for newly qualified nurses and those working in acute inpatient settings.

Impact of Watson's human caring-based health promotion program on caregivers of individuals with schizophrenia

BACKGROUND

Caring for people with schizophrenia is accompanied by challenges that impact caregiver health. We conducted this study to explore the effect of a Caring Science-Based health promotion program on the sense of coherence and well-being among caregivers of persons with schizophrenia.

METHODS

This randomized clinical trial with the Solomon four-group design was conducted on 72 caregivers randomly allocated into two intervention and two control groups. A health promotion program based on Watson's theory was performed individually through five face-to-face sessions and a four-week follow-up. Settings were the psychiatric centers of the three educational, specialty, and subspecialty Ibn-e-Sina, Moharary, and Hafez hospitals affiliated with Shiraz University of Medical Sciences (SUMS), south of Iran. The data were collected using a demographic information form, the Sense of Coherence Scale, and the Caregiver Well-Being Scale. One-way ANOVA, chi-square, Kruskal-Wallis, and independent t-test were used to determine the homogeneity at baseline. In the post-test, multiple between-groups and pairwise comparisons were assessed by One-way ANOVA and Tukey's post-hoc. Within-group comparisons were evaluated using paired t-tests. All tests were two-tailed, and the statistical level was considered 0.05.

RESULTS

Data analysis showed that the mean scores of caregiver sense of coherence and well-being from pre-intervention to post-intervention were significantly increased in the intervention groups (p < 0.001). At the same time, there were no significant differences in the control groups.

CONCLUSION

The health promotion program based on Watson's human caring theory facilitated ongoing intrapersonal, and holistic caring and improved the sense of coherence and well-being in caregivers of persons with schizophrenia. Hence, this intervention is recommended for developing healing care programs.

TRIAL REGISTRATION

https://www.irct.ir/trial/55040 : IRCT20111105008011N2 (11/04/2021).

Clinicians' perceptions of family involvement in the treatment of persons with psychotic disorders: a nested qualitative study

Background

Family involvement in mental health care ranges from basic practices to complex interventions such as Family psychoeducation, the latter being a well-documented treatment for psychotic disorders. The aim of this study was to explore clinicians' perceptions of the benefits and disadvantages of family involvement, including possible mediating factors and processes.

Methods

Nested in a randomised trial, which purpose was to implement Basic family involvement and support and Family psychoeducation in Norwegian community mental health centres during 2019-2020, this qualitative study is based on eight focus groups with implementation teams and five focus groups with ordinary clinicians. Using a purposive sampling strategy and semi-structured interview guides, focus groups were audio-recorded, transcribed verbatim, and analysed with reflexive thematic analysis.

Results

Four main themes were identified as perceived benefits: (1) Family psychoeducation-a concrete framework, (2) Reducing conflict and stress, (3) A triadic understanding, and (4) Being on the same team. Themes 2-4 formed an interconnected triad of mutually reinforcing elements and were further linked to three important clinician-facilitated sub-themes: a space for relatives' experiences, emotions and needs; a space for patients and relatives to discuss sensitive topics and an open line of communication between clinician and relative. Although far less frequent, three main themes were identified as perceived disadvantages or challenges: (1) Family psychoeducation-occasional poor model fit or difficulties following the framework, (2) Getting more involved than usual, and (3) Relatives as a potentially negative influence-important nonetheless.

Conclusions

The findings contribute to the understanding of the beneficial processes and outcomes of family involvement, as well as the critical role of the clinician in achieving these and possible challenges. They could also be used to inform future quantitative research on mediating factors and implementation efforts.

"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.

Implementation of Guidelines on Family Involvement for Persons with Psychotic Disorders (IFIP): A Cluster Randomised Controlled Trial

Family involvement is part of the evidence-based treatment for persons with psychotic disorders, yet is under-implemented despite guideline recommendations. This study assessed whether an implementation support programme increased the adherence to guidelines on family involvement, compared to guideline/manual only. In a cluster randomised design, community mental health centre units in South-East Norway went through stratified allocation to the experimental (n = 7) or control (n = 7) arm. Experimental clusters received an implementation support programme including clinical training and supervision, appointing a family coordinator and an implementation team, a toolkit, and fidelity measurements at baseline, 12, 18, and 24 months with on-site feedback and supervision. Control clusters received no such support and had fidelity measurements at baseline and 24 months without feedback. During fidelity measurements, adherence to the guidelines was measured with the basic family involvement and support scale, the general organizational index, and the family psychoeducation fidelity scale, the latter being the primary outcome. The scales consist of 12-14 items rated from 1 to 5. Data was analysed with an independent samples t-test, linear mixed models, and a tobit regression model. At 24 months, the mean scores were 4.00 or higher on all scales in the experimental arm, and the increase in adherence to the guidelines was significantly greater than in the control arm with p-values < 0.001. Large-scale implementation of guidelines on family involvement for persons with psychotic disorders in community mental health centres may be accomplished, with substantial implementation support.Trial Registration: ClinicalTrials.gov Identifier NCT03869177. Registered 11.03.19.

"Everyone means well but the one person who's really going to go to bat" - experiences and perspectives of substitute decision makers in caring for their loved ones with serious mental illness

In the era of on-going efforts to empower persons with mental illness to be independent decision makers as informed by the United Nations' Convention on the Rights of Persons with Disability (CRPD), family members acting as substitute decision makers (SDM) for people suffering from disabling serious mental illness (SMI) remain an integral part of the medical-legal system in psychiatric care in many parts of the world, including Canada; yet their experiences and perspectives are rarely studied. This explorative qualitative study examines the lived experiences and reflections of 14 family member SDMs in Toronto, Canada. Five key themes related to being SDM emerged: 1) Varied subjective understanding of the responsibility and authority of the SDM role; 2) Varied role demands and impact on SDMs' lives; 3) Challenges in dealing with the mental health system; 4) Leveraging decision making status to promote patient care; and 5) SDM role impact on family relationships. The need to improve SDM understanding of their role, acknowledging their value and care-taker burden, finding a balance for their involvement, and improving their support in efforts to enhance care for the patients are discussed.

Family Functioning and Health-Related Quality of Life in Parents of Children with Mental Illness

Previous research suggests that family dysfunction may be related to lower health-related quality of life (HRQoL) in parent caregivers, but it is unknown if this association exists in the context of child mental illness. Therefore, the objectives of this study were to compare HRQoL between parent caregivers and Canadian population norms using the Short Form 36 Health Survey (SF-36); examine associations between family functioning and parental HRQoL; and investigate whether child and parental factors moderate associations between family functioning and parental HRQoL. Cross-sectional data were collected from children receiving mental healthcare at a pediatric hospital and their parents (n = 97). Sample mean SF-36 scores were compared to Canadian population norms using t-tests and effect sizes were calculated. Multiple regression was used to evaluate associations between family functioning and parental physical and mental HRQoL, adjusting for sociodemographic and clinical covariates. Proposed moderators, including child age, sex, and externalizing disorder, and parental psychological distress, were tested as product-term interactions. Parents had significantly lower physical and mental HRQoL versus Canadian norms in most domains of the SF-36, and in the physical and mental component summary scores. Family functioning was not associated with parental physical HRQoL. However, lower family functioning predicted lower parental mental HRQoL. Tested variables did not moderate associations between family functioning and parental HRQoL. These findings support the uptake of approaches that strive for collaboration among healthcare providers, children, and their families (i.e., family-centered care) in child psychiatry settings. Future research should explore possible mediators and moderators of these associations.

An unexpected visitor and a sword play: a randomized controlled trial of collective narrative therapy groups for primary carers of people with schizophrenia

BACKGROUND

Most family carer support programs focus on supporting carers with caregiving-related knowledge and skills to help their family members who suffer from schizophrenia in their recovery process while carers' inner resources and preferred identities are less emphasized in the existing studies.

AIMS

The present study uses collective narrative therapy groups (CNTG) to promote the inner strengths and agency of family carers and help them to explore their preferred identities while caring for family members with schizophrenia.

METHOD

To ensure an evidence-based intervention, 89 Chinese family carers of people with schizophrenia took part in this three-wave longitudinal program evaluation study using a randomized controlled trial design.

RESULTS

Compared with the control group, family carers in CNTG reported better family relationships, a lesser caregiving burden, and more perceived inner resources. Repeated one-way ANOVA revealed that CNTG improved family relationships, the caregiving burden, the level of hope and inner resources in the posttest, and a statistically significantly better mental health condition in the follow-up.

CONCLUSION

This study shows that collective narrative psychotherapy is effective in supporting family carers of people with schizophrenia in Hong Kong. Based on the research findings, we discuss the strengths of the program and its implications for practitioners.

Experience, impact and needs of informal parental caregivers around the communication of a diagnosis of schizophrenia

AIMS

To qualitatively characterize the experience, impact and needs of informal family caregivers around the communication of a diagnosis of schizophrenia.

METHODS

In all, 13 informal family caregivers were recruited. All were parents. Semi-structured interviews were used to explore their experience of the diagnosis of schizophrenia, the impacts of the diagnosis and the needs related to the diagnosis around its communication. Interviews were recorded, transcribed, codes generated and mixed deductive-inductive thematic analysis undertaken.

RESULTS

Participants described receiving the diagnosis of schizophrenia for their relative as a devastating experience, although some nuanced the experience with a sense of relief of finally naming the disorder and getting access to care. Caregivers' experience and representations prior to hearing the diagnosis played an important role in the way the 'news' was internalized. The communication of the diagnosis constituted a starting point for acceptance of the reality of the illness in participants. Numerous unmet needs around the communication of the diagnosis were reported by participants, including personnalized support, specific explanations about the disorder and guidance on their role as caregiver.

CONCLUSION

A specific attention must be given to the communication of the diagnosis of schizophrenia to the informal family caregivers. Information giving must be early, comprehensive, personalized and embedded into tailored education and support programmes for caregivers to facilitate illness acceptance and adaptation.

The Lived Experiences of Family Members and Carers of People with Psychosis: A Bottom-Up Review Co-Written by Experts by Experience and Academics

Informal caregivers of individuals affected by psychotic disorder can play a key role in the recovery process. However, little research has been conducted on the lived experiences of carers and family members. We conducted a bottom-up (from lived experience to theory) review of first-person accounts, co-written between academics and experts by experience, to identify key experiential themes. First-person accounts of carers, relatives, and individuals with psychosis were screened and discussed in collaborative workshops involving individuals with lived experiences of psychosis, family members, and carers, representing various organizations. The lived experiences of family members and carers were characterized by experiential themes related to dealing with the unexpected news, the search for a reason behind the disorder, living with difficult and negative emotions, dealing with loss, feeling lost in fragmented healthcare systems, feeling invisible and wanting to be active partners in care, struggling to communicate with the affected person, fighting stigma and isolation, dealing with an uncertain future, and learning from one's mistakes and building resilience and hope. Our findings bring forth the voices of relatives and informal carers of people with psychosis, by highlighting some of the common themes of their lived experiences from the time of the initial diagnosis and throughout the different clinical stages of the disorder. Informal carers are key stakeholders who can play a strategic role, and their contributions in the recovery process merit recognition and active support by mental health professionals.

Expectations of caregivers of persons with severe mental illness from mental health rehabilitation services: A qualitative study

BACKGROUND

Mental health rehabilitation services (MHRS) play an essential role in addressing the diverse and often complex needs of persons with severe mental illness (SMI). The rehabilitation services are of utmost importance in training these patients to lead an independent and meaningful life. In India, caregivers of persons with SMI play a significant role in the decision-making process concerning treatment and rehabilitation.

AIM

The main objective of the present study was to understand and analyze the expectations of caregivers of persons with severe mental illness from mental health rehabilitation services in the Indian context.

METHOD

The present study is qualitative in nature. A semi-structured interview schedule was used to capture the caregivers' expectations. Fifteen caregivers who met inclusion and exclusion criteria were interviewed for the study. The data obtained was analyzed using Braun and Clarke's six-phase data analysis framework.

RESULTS

Thematic analysis of the data emerged into five themes, namely (1) 'proximity', (2) 'professionalism of staff', (3) 'treatment related expectations', (4) 'welfare benefits', and (5) 'infrastructure'. These themes and their sub-themes were subsequently discussed in the light of existing literature.

CONCLUSION

Caregivers of persons with SMI identified the most relevant as well as generic expectations from MHRS. Understanding these expectations can help improvise the existing services delivery system and help institutes, non-government organizations (NGOs) and other concerned entities working in mental health rehabilitation to develop service user friendly rehabilitation models.

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.

The lived experience of caring for someone with bipolar disorder: A qualitative study

Being a close family or friend of someone with bipolar disorder (BD) can lead to experiences of increased stress, anxiety and depressive symptoms related to the burden of caring. However, the lived experience of being a carer for a person with BD has not received significant research attention. This study aimed to gain further insight into the experiences of individuals in an informal caring role for someone with BD and determine what additional information and support these people need to take care of both themselves and the person they are caring for. Fifteen qualitative interviews were carried out with carers discussing their lived experiences with utilising coping strategies and supporting someone with BD. Following the interviews, thematic analysis was used to identify five key themes. These themes were: Separation of the person and the disorder, carer health and coping strategies, unpredictability and variability of symptoms, carer disillusionment and silencing, and story sharing and support needs. Overall, the findings highlighted the need for increased in-person and online support specifically tailored for carers with loved ones experiencing BD.

The Effect of Education and Telephone Follow-up on the Burden of Family Caregivers of Patients With Cancer

Introduction

Family caregivers of patients with cancer face a care burden due to the responsibilities and problems of providing care to the patients. Applying appropriate strategies to reduce the burden is essential.

Objective

The study aimed to determine the effect of education and telephone follow-up on family caregivers' burden on patients with cancer.

Methods

In this quasi-experimental study, 69 family caregivers of patients with cancer referred to only one chemotherapy center of a hospital in Lorestan province in Iran were recruited by convenience sampling method. They were randomly assigned to intervention (n  =  33) and control (n  =  36) groups. For the intervention group, two face-to-face training sessions and six telephone counseling sessions were held related to the care of the patients and self-care. The control group received only routine care. The family caregiver burden was measured by Novak and Gast Caregiver Burden Inventory (1989) completed before, immediately, and 6 weeks after the study. Data were analyzed by SPSS21 using independent t-tests, paired t-tests, and repeated measures.

Results

Both groups were homogeneous regarding demographic characteristics and the baseline care burden. The caregiver burden decreased significantly in the intervention group, so its score was 77.33  ±  8.49, 58.93  ±  8.03, and 52.78  ±  6.86 before the study, immediately after and 6 weeks later, respectively (p < .001). In the control group, there were no significant changes.

Conclusion

Education and telephone counseling reduced the burden on family caregivers. Therefore, this type of support is beneficial for providing holistic care and preserving the health of family caregivers.

Effects of the family support and psychoeducation program based on the Calgary Family Intervention Model on the coping, psychological distress and psychological resilience levels of the family caregivers of chronic psychiatric patients

AIMS

This study was aimed at investigating the effects of family support and psychoeducation program based on Calgary Family Intervention Model on coping, psychological distress and psychological resilience levels of families of chronic psychiatric patients.

METHODS

The sample of this quasi-experimental study consisted of the caregivers of chronic psychiatric patients who were admitted to the adult psychiatry inpatient and outpatient unit of a university hospital and the caregivers of chronic psychiatric patients registered with the Schizophrenia Solidarity Association. Nonparametric analysis was used in the analysis of the data.

RESULTS

It was found that there was a significant decrease between the mean distress scores the caregivers participating in the Calgary Family Intervention-Based Family Support and Psychoeducation Program obtained from the measurements before, right after, and 3 and 6 months after the intervention (p < 0.05). There was no statistically significant difference between the coping scores and psychological resilience scores the caregivers obtained from the measurements before, right after, and 3 and 6 months after the intervention (p > 0.05).

CONCLUSION

It was concluded that the family support and psychoeducation program based on the Calgary Family Intervention Model applied to family members giving care to individuals with chronic mental illnesses had positive effects on the general health status of the caregivers.

Scoping review of factors influencing the implementation of group psychoeducational initiatives for people experiencing mental health difficulties and their families

BACKGROUND

Despite evidence to support the effectiveness of psychoeducation for people experiencing mental health difficulties and their families, understanding issues around the implementation of such programmes is limited.

AIM

The aim of this scoping review was to synthesise the peer-reviewed literature on barriers and enablers influencing the implementation of group psychoeducation in adult mental health services.

METHODS

Using a pre-defined search strategy and PRISMA guidelines, four databases were systematically searched. Two reviewers independently screened and applied exclusion/inclusion criteria. Qualitative, quantitative, and mixed-methods studies were included if they provided empirical evidence on the barriers and enablers. Three reviewers independently extracted data. Following this, data were analysed using a five-level implementation framework.

RESULTS

Eight articles met the inclusion criteria. Barriers to implementation were identified at all five levels of the framework: participant; practitioner; intervention; organisational; and structural level. Enablers to implementation were evident at four levels: participant; provider; intervention; and organisational level.

CONCLUSIONS

The findings of the review provide preliminary information on factors that impact implementation. However, large-scale studies informed by implementation theories are required. In addition, other studies are needed to address the potential impact of different models of intervention and explore strategies to minimize obstacles and support sustainability.

Supports and Interventions for Carers of a Person with Depressive or Anxiety Symptomology: A Systematic Review

An increasing body of research attests to the capacity of evidence-based interventions to improve outcomes for informal carers. A review of suitable supports and interventions for carers of a person with depressive or anxiety symptomology is timely. This systematic review explores intervention suitability evidence for this carer group. Searches for relevant primary studies were conducted in six databases across a 15-year timeframe (October 2004-October 2019). Studies were assessed and compared narratively and thematically. Qualitative themes were synthesised with quantitative studies to explore the extent to which carer preferences were embedded in interventions. The initial literature search produced 13,183 studies. Six studies-three randomised controlled trials (RCTs) and three mixed-method studies-were included following a double-blinded screening process, a review of reference lists and risk of bias assessment. Included studies contributed either intervention efficacy or acceptability evidence. The synthesis of qualitative themes with quantitative studies found that carer-specific needs and targeted psychoeducation were featured in interventions from all six quantitative studies. Current evidence for appropriate supports and interventions for this carer group is limited. The review uncovers a lack of interventions for carers of a person with anxiety symptomology and limited intervention suitability evidence for carers of a person with depressive symptomology. More research is needed to explore the needs and preferences of this carer group, and how best to support them.

Assessment of the treatment needs of community recovery Services in Spain: From the perspective of service users, families, and mental health professionals

Profile of Community Recovery Services users has changed over the years and has become more diverse. To explore the evolution of treatment needs, this study aimed to identify users' needs, from the point of view of different agents implicated in the recovery process. We explored the consistency between the agents using the focus group technique. We defined four groups (n = 58): service users, family members, professionals, and referring professionals. We pre-identified topics related to recovery, such as illness-related losses, imaginary of CRS, expectations, activities, and life goals. All agents recognised losses related to the mental illness, the need for carrying activities out of the Community Recovery Services, and for including families in the recovery process. The groups differed in some areas, such as the identification of activities that should be encouraged, or the importance of promoting vital expectations. Our findings suggest that it is important to identify the needs of different agents involved in the recovery process. There is consistency in the service users' needs, but there are some differences that need to be considered. Interventions should be personalised, covering functional, cognitive, and relational losses related to the mental illness.

Factors Associated with Quality of Life in Relatives of Adults with Serious Mental Illness: A Systematic Review

Caring for a family member with a serious mental illness often has an impact on the quality of life (QoL) of caregivers. This could have negative repercussions on their caring skills and thus affect the care provided to that individual. The aim of this paper is to identify current evidence on QoL factors affecting relatives of individuals suffering from serious mental illness. A systematic review related to the research question was conducted in six databases by two independent reviewers. The QoL factors of relatives include sociodemographic, contextual, psychological, physical, and patient factors. The findings are consistent with the results of previous research. Mental health professionals may support a family with a member diagnosed with a serious mental illness by enhancing their education about QoL factors, which would trigger and promote protective factors so that family members could assess and act on them on an ongoing basis.

Leading from the Middle: Practical Innovation in Public Mental Health

Leaders in public mental health are responsible for ensuring the care environment is conducive to provider wellbeing, and ultimately patient care. Given the effects of stress and burnout, healthcare organizations must explore interventions to support their employees. The Leadership + Innovation Lab is a pilot project focused on enhancing leadership skills, innovation capacity, and peer connections among clinical managers. Participants executed individual or group projects to improve the care environment and co-created a peer consultation program. They reported increased connection with peers, innovation and leadership skills, and capacity to facilitate a better experience for their provider staff as a result of the program. This model can be used in other settings to help achieve the goals of the Quadruple Aim and improve communication.

Barriers and facilitators when implementing family involvement for persons with psychotic disorders in community mental health centres - a nested qualitative study

Background

The uptake of family involvement in health care services for patients with psychotic disorders is poor, despite a clear evidence base, socio-economic and moral justifications, policy, and guideline recommendations. To respond to this knowledge-practice gap, we established the cluster randomised controlled trial: Implementation of guidelines on Family Involvement for persons with Psychotic disorders in community mental health centres (IFIP). Nested in the IFIP trial, this sub-study aims to explore what organisational and clinical barriers and facilitators local implementation teams and clinicians experience when implementing family involvement in mental health care for persons with psychotic disorders.

Methods

We performed 21 semi-structured focus groups, including 75 participants in total. Implementation team members were interviewed at the initial and middle phases of the intervention period, while clinicians who were not in the implementation team were interviewed in the late phase. A purposive sampling approach was used to recruit participants with various engagement in the implementation process. Data were analysed using manifest content analysis.

Results

Organisational barriers to involvement included: 1) Lack of shared knowledge, perceptions, and practice 2) Lack of routines 3) Lack of resources and logistics. Clinical barriers included: 4) Patient-related factors 5) Relative-related factors 6) Provider-related factors. Organisational facilitators for involvement included: 1) Whole-ward approach 2) Appointed and dedicated roles 3) Standardisation and routines. Clinical facilitators included: 4) External implementation support 5) Understanding, skills, and self-efficacy among mental health professionals 6) Awareness and attitudes among mental health professionals.

Conclusions

Implementing family involvement in health care services for persons with psychotic disorders is possible through a whole-ward and multi-level approach, ensured by organisational- and leadership commitment. Providing training in family psychoeducation to all staff, establishing routines to offer a basic level of family involvement to all patients, and ensuring that clinicians get experience with family involvement, reduce or dissolve core barriers. Having access to external implementation support appears decisive to initiate, promote and evaluate implementation. Our findings also point to future policy, practice and implementation developments to offer adequate treatment and support to all patients with severe mental illness and their families.

Trial registration

ClinicalTrials.gov Identifier NCT03869177. Registered 11.03.19.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08489-y.

An online program with individualized vs automated support for significant others of depressed individuals - study protocol of a randomized controlled trial

BACKGROUND

Due to budget restrictions in mental health care, non-professional caregivers are increasingly burdened with the emotional and practical care for their depressed relatives. However, informal family caregiving is mostly a stressful role with negative consequences on the physical and mental health of the caretakers to the extent that they have an elevated risk of experiencing psychiatric disorders themselves. While psychoeducation for relatives of depressed individuals showed positive results both in terms of the caretakers' strain and the depressive symptoms of the affected person, there are major barriers to participate in presence in those programs. Digital programs might be a viable alternative. We found no empirically evaluated digital program available for informal caregivers of depressed patients.

METHODS

An online program for relatives of depressed individuals has been developed including four interactive modules on 1) psychoeducation, 2) how to strengthen the relationship with the depressed person, 3) how to deal with the depressive symptoms of the patient, and 4) find the right balance between caring for the depressed person and self-care. We investigate if this self-help program is more effective when used with individualized versus automated e-mail support, and if both supported conditions are more effective than treatment-as-usual (TAU in form of written information material) in terms of the risk of mental diseases in caregivers. The primary outcome is the reduction of the caregiver's nonspecific mental distress as measured by the change of the Kessler Psychological Distress Scale score from baseline to four weeks after randomization. Caregivers (n = 500:500:250) will be randomized to one of the three conditions.

DISCUSSION

Psychological support for caregivers of individuals with mental disorders such as depression should be offered as part of integrated services. There is a huge potential to develop and implement interactive online approaches to support informal caregivers of patients with depression to function in their multiple roles and to help them to remain healthy.

TRIAL REGISTRATION

DRKS, DRKS00025241 . Registered 5 Mai 2021.

Caregiving-related experiences associated with depression severity and its symptomatology among caregivers of individuals with a severe mental disorder: an online cross-sectional study

Caring for a relative with a severe mental disorder puts family caregivers to a great risk of depression. While overall caregiving burden is a strong predictor of depression, the contribution of the various dimensions of burden to caregivers' depression as well as their relationships with depressive symptoms has received little attention. 384 family caregivers completed a cross-sectional online survey including the Center for Epidemiological Studies Depression (CES-D) scale, the Zarit Burden Interview (ZBI), and the Brief Experience of Caregiving Inventory (BECI), measuring caregiving burden and experience. We estimated the structure of the relationships between caregiving experiences (i.e., ZBI and BECI subscales) and CES-D symptoms using a network approach. Negative Emotion/Consequences, (lack of) Positive Personal Experience, and Stigma/Effects on Family were the most connected caregiving dimensions to depression. To untangle the role of the Negative Emotion/Consequences component (by far the most central node in estimated networks), a secondary analysis incorporating its composing items was estimated. Losing control over life, feeling strained around the relative and impaired self-perceived health emerged as central nodes. Interestingly, these caregiving-related dimensions or experiences were differentially connected to depressive symptoms. We discuss how these findings might help future research and inform tailored psychoeducational interventions for family caregivers of people with a severe mental disorder.

Integrated Health and Social Services for People With Chronic Mental Health Problems: People Are More Important Than Processes. Insights From a Multiple Case Study in Swedish Psychiatry

Three mental health organizations, one merged with, one formally cooperating with, and one without formal links to social services were analyzed through the experience of staff, patients and relatives in order to elucidate what approaches best promoted service coordination. Seventeen staff and eight patients or relatives, recruited from the three organizations, participated in semi-structured interviews, guided by pre-selected categories derived from previous research about coordination and care processes. Directed content analysis was used to identify and categorize meaning units. Both staff and patients raised the same concerns. Organized collaboration between psychiatric care and social services addressed only some of patients' challenges. More important was patient access to financial and social assistance. The organizational arrangements were not referred to, whereas case management was seen as crucial. In many instances relatives have to act as case managers. Service integration in mental health has to include, in addition to social services, other authorities like social insurance and employment agencies. A case manager knowledgeable about all welfare services is best positioned to promote that “extended integration”. Relatives often have to take this responsibility to support this fragile group of patients. This observed importance of case management is supported by previous research in mental health and primary care. The role of relatives should be acknowledged and supported by those services.

COVID-19 lockdown - who cares? The first lockdown from the perspective of relatives of people with severe mental illness

Background

Informal care is vital to many people with severe mental illness under normal circumstances. Little is known about how extraordinary circumstances affect relatives with a family member with mental illness. This study investigated the consequences of the first COVID-19 lockdown in Norway from the perspective of relatives of persons with psychotic- and/or bipolar disorders: What were the challenges and for whom?

Method

Relatives were invited to complete an online survey shortly after the first lockdown was initiated. Both quantitative and qualitative data were collected concerning experiences of relatives’ own and their affected family members’ health and situation. Two hundred and seventy-nine relatives completed the survey, mostly mothers and partners.

Results

One-third of the relatives reported considerable deterioration in their family members’ mental health, and a substantial minority worried about severe self-harm or suicide. Main themes in the qualitative analyses were “Isolation and its effects on mental health”, “Worrying about the pandemic and its consequences”, “Increased symptomatology” and “Suicide”. Being a relative during the lockdown put heavy strain on the relatives’ own health, in particular disturbance of sleep, concentration, and the ability to take care of others in the family. Relatives of family members with psychotic bipolar disorder, not currently in treatment, or living with their family experienced the situation especially challenging.

Conclusions

Many relatives found the first lockdown hard for their family. Efforts to integrate relatives’ perspectives in health care and contingency plans under normal circumstances could potentially alleviate some of the extra burden experienced by families during extraordinary circumstances.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13458-5.

Quality prescribing in early psychosis: key pharmacotherapy principles

OBJECTIVE

To present a practical, easy-to-implement clinical framework designed to support evidence-based quality prescribing for people with early psychosis.

METHOD

Identification and explanation of key principles relating to evidence-based pharmacotherapy for people with early psychosis. These were derived from the literature, practice guidelines and clinical experience.

RESULTS

Key principles include (1) medication choice informed by adverse effects; (2) metabolic monitoring at baseline and at regular intervals; (3) comprehensive and regular medication risk-benefit assessment and psychoeducation; (4) early consideration of long-acting injectable formulations (preferably driven by informed patient choice); (5) identification and treatment of comorbid mood disorders and (6) early consideration of clozapine when treatment refractory criteria are met.

CONCLUSIONS

Current prescribing practices do not align with the well-established evidence for quality pharmacotherapy in early psychosis. Adopting evidence-based prescribing practices for people with early psychosis will improve outcomes.

Interventions that support unpaid carers of adult mental health inpatients: a scoping review

BACKGROUND

Unpaid carers of adult mental health inpatients often lack support for their well-being and feel excluded from decisions about patient care.

AIMS

This scoping review aimed to: synthesise the peer-reviewed literature evaluating the outcomes of brief interventions for unpaid carers of adult mental health inpatients, identify transferable lessons for evidenced-informed practice, and establish future research priorities.

METHODS

PRISMA scoping review guidelines were followed to search 12 databases using predefined search terms. Two reviewers independently screened papers and applied exclusion/inclusion criteria. Studies were included if they evaluated the impact or outcomes of interventions. Two reviewers extracted data and assessed study quality. Data were synthesised to categorise types of interventions and evidence for their outcomes.

RESULTS

16 papers met the inclusion criteria, and five types of interventions were identified: those that aimed to (1) increase carer involvement in inpatient care; (2) facilitate organisational change to increase carer support and involvement; (3) provide carers with support; (4) deliver psychoeducation and offer support; and (5) reduce carer stress and improve coping skills.

CONCLUSIONS

Whilst evidence of intervention effectiveness was promising, the quality of studies was generally weak. More research is needed to develop an evidence-informed approach to supporting carers during inpatient stays.

Telehealth-Based Psychoeducation for Caregivers: The Family Intervention in Recent-Onset Schizophrenia Treatment Study

BACKGROUND

Schizophrenia is a lifelong illness that requires long-term treatment and caregiving. Family psychoeducation (FP) has been shown to lessen caregiver burden, improve caregiver functioning, and improve outcomes in patients. However, the impact of FP delivered specifically to caregivers on patient outcomes has not been well explored, particularly for early schizophrenia. Furthermore, there is a lack of research examining the benefits of telehealth-based psychoeducation for caregivers on either patient or caregiver outcomes.

OBJECTIVE

The Family Intervention in Recent-Onset Schizophrenia Treatment (FIRST) study is a randomized controlled trial of patients with schizophrenia spectrum disorders and their caregivers, which is designed to evaluate the effect of telehealth-based, caregiver-focused, study-provided psychoeducation versus usual care (UC) on patient treatment failure (TF). The impact of study-provided psychoeducation on caregiver burden is also investigated.

METHODS

Eligible patients and their designated caregivers were randomly assigned to either the study-provided psychoeducation (≤16 sessions of telehealth-based psychoeducation over 6 months) or UC group, stratified by antipsychotic treatment (paliperidone palmitate or oral antipsychotic). The major TF events (ie, psychiatric hospitalization or intervention, arrest or incarceration, and suicide attempts) were assessed at 3, 6, and 12 months after baseline. A proportional means model using mean cumulative function was used to assess between-group differences in the mean cumulative number of TF events over 12 months. Caregiver burden was assessed using the Involvement Evaluation Questionnaire and 12-item Short Form Health Survey.

RESULTS

A total of 148 pairs of participants were enrolled in the study, of whom 96 (64.9%) patients and 94 (63.5%) caregivers completed the 12-month follow-up. The mean number of sessions in the study-provided psychoeducation group was 7.7 (SD 5.9). No differences were observed between the study-provided psychoeducation and UC groups in patient outcomes (rates of TF: 70% vs 67%; P=.90) or measures of caregiver burden (assessment of caregiver distress and physical and mental health). However, post hoc analyses revealed lower relapse rates in patients who received paliperidone palmitate than in those who received oral antipsychotics at all time points. Although the FIRST study did not meet the primary end point, several key lessons were identified to inform future caregiver-focused, telehealth-based FP interventions. Lack of study-provided psychoeducation, focus on caregiver-only intervention, difficulties with enrollment, and caregiver-treatment team coordination may have affected the outcomes of the FIRST study.

CONCLUSIONS

Key insights from the FIRST study suggest the potential importance of supporting sufficient caregiver engagement; communication between clinicians, patients, and family members regarding treatment plans; and solidifying the relationship between clinicians providing psychoeducation to the caregiver and patient treatment team.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02600741; http://clinicaltrials.gov/ct2/show/NCT02600741.

Effect of digital psychoeducation and peer support on the mental health of family carers supporting individuals with psychosis in England (COPe-support): a randomised clinical trial

Background

Psychoeducation delivered face-to-face is effective in alleviating mental health morbidities in family carers of individuals with psychosis. However, research in such interventions delivered online is scarce. We evaluated the effectiveness of a digital multicomponent intervention—COPe-support—in improving carers' mental wellbeing and caregiving-related outcomes.

Methods

In this two-arm, individually randomised, superiority trial, people aged 18 years or older who provided at least weekly support in any format for a relative or close friend affected by psychosis across England were randomly assigned (1:1) to either COPe-support or a passive online information resource using an independent online system. Participants were recruited through 30 mental health UK National Health Service trusts. The study team were masked to allocation and assessment of outcomes as all data collection took place online. Participants had access to either condition for 40 weeks and were advised to spend at least half an hour per week over the initial 20 weeks to go through materials at their own pace and to allow time to integrate knowledge and skills learned into practice. It was not feasible to mask participants or the online facilitator to intervention allocation. COPe-support provided psychoeducation on psychosis-related caregiving strategies and forums with professionals and other carers, and the control intervention comprised a passive online information resource. The primary outcome at 20 weeks was mental wellbeing measured by the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS; minimally clinically important difference [MCID] 3). This trial is registered with ISRCTN, 89563420.

Findings

Between March 1, 2018, and Feb 14, 2020, 407 participants were randomly assigned, with 204 allocated to COPe-support and 203 allocated to control. The participants (mean age 53·1 years, SD 13·2) were mostly female (330 [81%] of 407 participants) and White (359 [88%] of 407 participants). 346 (85%) of 407 participants provided primary endpoint data, 174 (85%) of 204 participants in the COPe-support group and 172 (85%) of 203 participants in the control group. The mean WEMWBS score at 20 weeks was 44·5 (SD 8·31) for the COPe-support group and 43·3 (9·19) for the control group. We found no evidence of a difference in wellbeing between the two groups (adjusted mean difference 0·37, 95% CI –1·14 to 1·88; p=0·63). In the COPe-support group, 106 (52%) of 204 participants met the complier definition of a minimum of two logins in separate weeks. The complier average causal effect analysis increased the difference in WEMWBS scores (adjusted difference 0·83, 95% CI –1·45 to 3·11; p=0·47), but this was lower than the MCID. There were no adverse events.

Interpretation

Our findings did not support the use of COPe-support over a passive online information resource. However, further research to optimise digital interventions adjunctive to face-to-face support for carers remains important.

Funding

National Institute for Health Research.

Investigating the effects of post-discharge care services for patients with severe psychiatric illnesses on their caregivers' burnout in Sanandaj

Family-based caregivers of psychiatric patients are the backbone of the healthcare system and are, in fact, generally considered as patients themselves. Their commitment and obligation to take care of the in-need and disabled patients in the family can lead to their psychological destruction. This paper attempts to investigate the effects of post-discharge care for patients with severe psychiatric illnesses on the burnout of their caregivers in the Qods Hospital of Sanandaj. This before-after study was performed on 72 subjects divided into two groups of 36, all of whom were chosen from the caregivers of the case and control subjects from family members of the psychiatric patients discharged from Qods psychiatric hospital in 2016. The study was effectively conducted with a control group design. The case group included patients who received home-care services after being discharged, and the caregiver group received nothing but regular care. First, using the hospital files, personal characteristics and diagnosis of the patient were recorded, thus the caregivers' characteristics and their burnout and psychological exhaustion severity were collected by caregiver burden inventory. The data were presented using descriptive-analytic indexes. The results represented that most of the caregivers (95.8%) suffered from moderate to severe burdens at the time of discharge. In using the Kolmogorov-Smirnov test, pre-test scores in two groups supported the normal hypotheses of the data (P = 0.55). Also, the level of significance in the covariance test showed the efficacy of intervention after the test (P = 0.000). In this study, most of the patients' caregivers with severe mental illnesses suffered from moderate to a severe burden, which, of course, seems to be more than other similar studies. Differences in social, cultural, and special regional conditions, as well as the type of applied questionnaire, were of significance. However, despite the mentioned difference, as it is true for other similar studies in Iran and other countries, home-care services have a significant effect on reducing the caregivers' burden after one year. Researches could, besides reducing the burnout of caregivers, provide a model which could help patients in the deprived areas without removing cultural and family roots and without diminishing the role of the family.

Family therapy for persons with schizophrenia: neglected yet important

Since the 1950s, the observed disturbances in family relationships in which a member has been diagnosed as having schizophrenia has led many systemic family therapists to the hypothesis that these family interactions may have preceded the onset of illness and contributed to it. However, attempts at using traditional family therapy with families of patients with schizophrenia were not successful or widely adopted. With the introduction of neuroleptic medication, the treatment of schizophrenia changed dramatically, and patients often returned to their family in varying stages of partial remission, increasing the burden on relatives. Furthermore, research based on the expressed emotion concept demonstrated that the chance of relapse increases by a factor of 2.5 when a patient returns to a high-EE-family in contrast to a low-EE-family environment; consequently, the vulnerability-stress model started to guide treatment development. Based on these developments, since 1980, several psychoeducational family management programs have been evaluated showing a significant reduction in relapse when compared to standard psychiatric care from 49 to 13%. To date, at least 50 RCT studies have been published showing the effectiveness of family interventions in various culturally diverse countries. Therefore, according to the NICE and other guidelines, family intervention should be offered to all families of people with psychosis who live with or are in close contact with the patient, in conjunction with neuroleptic treatment. Despite this strong recommendation, family involvement is under-implemented in mental health care, despite its strong scientific, economic, legal and moral basis. To improve the psychosocial health of patients with psychotic disorders and their relatives, more research is necessary, as well as more training for professionals in effective family interventions.

The effect of structured psychoeducation on caregiver burden in carers of patients with schizophrenia in Nigeria: A 12-week follow-up investigation

Background

Despite robust evidence of the huge burden of caregiving amongst caregivers of patients with schizophrenia, there is a paucity of data in Africa on the interventions to address this enormous burden of caregiving.

Aim

This study aimed to determine the effect of structured psychoeducation intervention on the burden of caregiving in comparison with ‘care as usual’ in a Nigerian Psychiatric Hospital.

Setting

This study was done at the out-patient and in-patient units of the Federal Neuropsychiatric Hospital, Enugu, Nigeria.

Methods

Caregivers of inpatients who fulfilled the International Classification of Diseases (ICD-10) criteria for diagnosis of schizophrenia were recruited for the study. The caregivers were then allocated into two groups (Group A received structured psychoeducation intervention in addition to ‘care as usual’ whilst group B received only ‘care as usual’). After the baseline assessment, the caregivers were followed up every 4 weeks for a period of 12 weeks. At each interval of follow-up, caregivers were assessed for caregivers’ burden using the Zarit Burden Interview (ZBI). Repeated measures analysis of variance (mixed type) was used to determine the effects of the interventions on caregivers’ burden in the two arms of the study across the intervals of follow-up.

Results

The attrition rate at week 12 was 10.7%; leaving 130 for the assessment of outcome variable at the end of follow-up. Structured psychoeducation intervention was significantly better than ‘care as usual’ in ameliorating caregivers’ burden [F (1, 123) = 21.75, p < 0.001, Partial Eta Squared = 0.39].

Conclusion

These findings seem to suggest that caregivers who received structured psychoeducation intervention experienced a greater reduction in caregiver burden than those who received ‘care as usual’. Whilst the study addressed short-term effect, the findings of this study are in accord with other studies that have supported the impression that psychoeducational family-based intervention is useful with regard to caregiver burden.

Perceived Acceptability and Experiences of a Digital Psychoeducation and Peer Support Intervention (COPe-support): Interview Study With Carers Supporting Individuals With Psychosis

Background

Web-based mental health interventions offer a novel, accessible, and self-paced approach to care delivery to family carers (ie, relatives and close friends who support a loved one with psychosis). We coproduced COPe-support (Carers fOr People with Psychosis e-support), a psychoeducational intervention delivered via an enriched web-based learning environment with network support from professionals and peers. In addition to the rigorous investigation of the effectiveness of COPe-support on the well-being of carers and mental health outcomes, it is imperative to understand the experiences of using the web-based intervention by carers and its associated web-based implementation and facilitation strategies.

Objective

This study aims to explore the experiences of carers and perceived acceptability of COPe-support and its different components, how carers found engagement with COPe-support affected their own well-being and caregiving, and the ideas of carers for improving COPe-support and its delivery to inform any future wider implementation.

Methods

We conducted a qualitative study, individually interviewing 35 carers, following their use of COPe-support for 8 months through a web-based, randomized controlled trial across England. A semistructured guide with open-ended questions was used to explore the experiences of carers and perceived acceptability of the intervention and their ideas to improve the provision. All interviews were conducted remotely through mobile phones or internet communication media, audio recorded and transcribed verbatim. We used a thematic analysis framework to analyze the data.

Results

Three key themes were identified: remote, flexible, and personalized support; impacts on well-being and outlook on caregiving; and future implementation and integration with existing services. Overall, carers found COPe-support a flexible source of knowledge and support from professionals and peers that they could personalize to suit their own needs and convenience. Participants described gaining self-confidence, hope, and a sense of connectivity with others in a similar situation, which helped ameliorate isolation and perceived stigma. Most importantly, COPe-support promoted self-care among the carers themselves. Participants’ experiences, use, and activity on COPe-support varied greatly and differed among carers of various ages and levels of computer literacy.

Conclusions

Nearly all participants had a positive experience with COPe-support and supported its wider implementation as a beneficial adjunctive support resource for carers in the future. Any future scale-up of such an intervention needs to consider feedback from carers and suggestions for further improvement. These included having more graphics and audiovisual content materials, improving the navigation, and building in more interactional and customization options to suit various user styles, such as emoji reactions, live web-based chat, opting in and out of updates, and choosing the frequency of reminders. To ensure successful implementation, we should also consider factors pertinent to reaching more carers and integrating the web-based resources with other conventional services.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN) 89563420; https://www.isrctn.com/ISRCTN89563420

International Registered Report Identifier (IRRID)

RR2-10.1186/s12888-020-02528-w