Siblings of individuals with first-episode psychosis: understanding their experiences and needs

Distress, burden, and wellbeing in siblings of people with mental illness: a mixed studies systematic review and meta-analysis

BACKGROUND

Family members of people with mental illness (MI) may experience a host of psychological adversities such as increased stress, burden, and reduced wellbeing. However, relatively little is known about siblings. This study aimed to characterise the experience of distress (viz. depressive and anxiety symptoms), burden, and wellbeing in siblings of people with MI.

METHODS

Studies reporting on quantitative measures of depression, anxiety, burden, or wellbeing in siblings; and/or qualitative findings on siblings' experience were eligible. The literature search was conducted up until 20th October 2022.

RESULTS

Sixty-two studies comprising data from 3744 siblings were included. The pooled mean percentage of depressive symptoms fell in the mild range at 15.71 (k = 28, N = 2187, 95% CI 12.99-18.43) and anxiety symptoms fell in the minimal range at 22.45 (k = 16, N = 1122, 95% CI 17.09-27.80). Moderator analyses indicate that siblings of people with a schizophrenia spectrum disorder experience greater depressive symptoms than siblings of people with other types of MI (β = -16.38, p < 0.001). Qualitative findings suggest that individuals may be particularly vulnerable during their siblings' illness onset and times of relapse. Limited communication, confusion about MI, and the need to compensate may contribute to siblings' distress and/or burden. Siblings' experience of wellbeing and caregiving were closely related.

CONCLUSION

This review highlights the complex psychological experience of siblings and the need for greater research and clinical support for this important yet often overlooked cohort.

Filling the Void: The Role of Adult Siblings Caring for a Brother or Sister With Severe Mental Illness

Little is known about the role of adult siblings’ caregiver role within the context of mental illness. Therefore, our purpose was to explore how siblings narrate their experiences of being the main caregivers of a brother or sister with severe mental illness and how they cooperate with their ill sibling and their family of origin. We used a narrative hermeneutic approach and performed a secondary analysis of two interviews of siblings derived from a study of peoples’ experiences of hearing voices. The findings illuminate the participants’ multifaceted roles and how differently siblings might deal with the multiple challenges of caring for an ill sibling. The mediating role between their ill sibling and their family of origin to reestablish the broken family bonds was a significant aspect. Nurses’ awareness of the important and multidimensional role of caregiving siblings can improve the provision of family support and promote involvement of siblings in the treatment of an ill family member.

My sibling's mental illness: An interpretative phenomenological analysis of experiences of having an adult sibling with a mental illness in semi-rural South Africa

Background

When there is a lack of resources in the community to support deinstitutionalisation, the siblings of an individual with a mental illness are the ones who are the most affected and vulnerable. Nevertheless, sibling care work is still largely unacknowledged in the mental health sector in low- and middle-income countries.

Aim

This article describes and interprets the lived experiences of 'black' isiXhosa-speaking individuals having a sibling with a mental illness, to shed light on how mental health professionals might support and sustain the involvement of individuals in the treatment and care of their sibling.

Setting

The study was conducted in a semi-rural town in the Eastern Cape of South Africa.

Methods

The study employed a qualitative research design using interpretative phenomenological analysis as the research method. Semi-structured interviews were conducted and analysed.

Results

The findings present interview extracts which give voice to participants' experiences of financial burden, social burden and stigma, and of engaging with psychiatric treatment while providing care for their mentally ill sibling. Findings also highlight the positive aspects of caring for a sibling with a mental illness.

Conclusion

This study specifically highlights the gendered nature of care work and siblings' increased understanding of mental illness by virtue of their relationship with their brother or sister, thereby possibly pointing to sibling relationships as valuable relational resources for challenging stigma. The study findings suggest that calls for greater cooperation between healing belief systems should include dialogue with western religious belief systems alongside traditional healing belief systems.

Understanding Individual and Family Experiences Associated with DUP: Lessons from the Early Assessment and Support Alliance (EASA) Program in Oregon, USA

Research shows that a longer duration of untreated psychosis (DUP) is associated with worse psychiatric outcomes, with average length of DUP of 73 weeks in the U.S. The aim was to examine the DUP period for first episode psychosis in Oregon, with a focus on the processes between the first positive symptoms and first treatment. To investigate DUP, researchers used methods consistent with grounded theory to collect data from 9 participants and their families about the process between onset of psychotic symptoms and entrance into treatment. Results suggest that recognition of symptoms was the primary driver of help-seeking in this study, and this was influenced by type of symptom as well as the presence or absence of supportive others, which in most cases was regular family contact. Implications indicate a need for in-depth research on individual and family recognition of symptoms, as well as underscoring the need for community education.

Adult Sibling Relationships: Perspectives of Service Users with Mental Health Difficulties

Little is known about the perceptions of sibling relationships from the direct perspective of service users with mental health difficulties; this study aimed to address this gap. Semi-structured interviews were carried out with adult male inpatients who had severe and enduring mental health difficulties. Interpretative phenomenological analysis was used to analyse the data and revealed three main themes: (1) The closeness of the sibling bond; (2) The change in sibling dynamics following diagnosis and admission; (3) Siblings' contribution to mental health and recovery. The implications of involving siblings in care and the benefits of service user led research are discussed.

Comparison of relationships among French adult siblings with or without schizophrenia using the ASRQ-S: mediating effect on emotional distress

BACKGROUND

Good sibling relationships in adulthood are known to be a protective factor for mental health. The present study examined and compared the relationships of siblings with either a healthy brother or sister or one experiencing schizophrenia.

METHODS

In the first phase, we ran a statistical comparison of the two sibling groups on the quality of their sibling relationships (warmth, conflict, and rivalry), emotional distress, and self-esteem. In the second phase, we looked at whether the quality of the sibling relationship modifies the impact of having a brother or sister with schizophrenia on emotional distress and self-esteem.

RESULTS

Results showed that sibling relationships in schizophrenia are less warm and are characterized by heightened rivalry and conflict. In addition, analysis revealed a mediating effect of sibling relationship on the emotional distress of siblings with a brother/sister diagnosed with schizophrenia.

CONCLUSION

More needs to be done to enhance the mental health of adults who have a brother or sister with schizophrenia, notably via their sibling relationships.

The Lived Experience of First-Episode Psychosis: A Systematic Review and Metasynthesis of Qualitative Studies

Both research and care have focused on first episodes of psychosis (FEPs) as a way to address the issue of early stages of schizophrenia and to reduce the duration of untreated psychosis. The objective of this study was to explore specifically the lived experience of FEP from the point of view of patients and their families by applying a metasynthetic approach, including a systematic review of the literature and analyses of qualitative studies on the subject. This metasynthesis follows thematic synthesis procedures. Four databases were systematically searched for qualitative studies reporting FEP from the patient or family's perspective. Article quality was assessed with the Critical Appraisal Skills Program. Thematic analysis was used to identify key themes and synthesize them. Thirty-eight articles were included, covering data from 554 participants (378 patients and 176 relatives). Three themes emerged from the analyses: (1) When and how does a FEP start? (2) What are its negative and positive aspects? (3) How do patients and families recount FEPs? Our results found important discrepancies between the experiences of patients and those of their families, especially regarding positive aspects. In light of the confusion reported by patients and notable in our results, we also discuss the gap between the name, FEP, and the lived experience of patients and family members in order to explore its practical implications.

Explaining Differences Between Sibling Relationships in Schizophrenia and Nonclinical Sibling Relationships

BACKGROUND

Good sibling relationships in adulthood are known to be a protective factor for mental health. The quality of these relationships is influence by the sibship's inherent characteristics (e.g., birth order, number of brothers and sisters, sex composition, age gaps). The present study explored whether these same determinants can help to explain how individuals experience their relationship with a sibling who has been diagnosed with schizophrenia.

METHOD

A total of 374 adults completed the Adult Sibling Relationship Questionnaire, a scale that probes the quality of these relationships on three dimensions: warmth, conflict, and rivalry. We also collected sociodemographic data and information about family structure from each of the participants. Participants were divided into two matched groups: nonclinical sibling group (n = 187) or schizophrenia sibling group (n = 187). Regression analyses were conducted to extract possible predictors of sibling relationship quality for each group. Further regression analyses then focused exclusively on relationships with an ill sibling, in order to study the role of disease-related variables in explaining each of the three dimensions.

RESULTS

Results showed that sociodemographic and family structure data explained a significant proportion of variance in the sibling relationship, but solely for nonclinical siblings. When participants had a sibling with schizophrenia, we found that disease-related variables (symptom severity, frequency of treatment) also had to be included to predict the conflict dimension.

CONCLUSIONS

Our results suggest that feelings of conflict experienced by the schizophrenia sibling group were fueled by the symptoms the ill person displayed. Healthy brothers and sisters probably have only a poor understanding of these symptoms. This could be improved by supporting them and helping them learn more about the disease. Future research will have to prove that providing such support for siblings does indeed improve the quality of their sibling relationships and, by so doing, enhance the wellbeing of both members of a sibling dyad.

Decision Making About Pathways Through Care for Racially and Ethnically Diverse Young Adults With Early Psychosis

OBJECTIVE

This study elicited factors that shaped treatment decision making for young adults and their key supporters after an initial hospitalization for psychosis to generate hypotheses about how to improve service engagement.

METHODS

This prospective, longitudinal, ethnographic study (using home visits, interviews, and hospital-based fieldwork) asked what mattered to 18 young adults primarily from racial-ethnic minority groups and 19 of their self-identified key supporters (N=37) as they made decisions about treatment during the 12-week critical period after an initial hospitalization for psychosis. The analytical approach used inductive coding and constructivist grounded theory methods to analyze interview transcripts and field notes from home visits and generate hypotheses about key factors that seemed to affect treatment decision making. Factors were ranked in order of frequency across all participants (overall, young adults only, and key supporters only).

RESULTS

Among the 37 total participants (young adults and key supporters), more than two-thirds were concerned with getting back to normal, the insufficient mental health care on offer, police involvement in their pathway to care, feeling worse, and needing help with repairing strained relationships. More than one-half were concerned with how young adults would be able to live independently in the future, paying for mental health care, distrusting mental health diagnoses, managing social pressure to use substances, feeling disempowered by hospitalization experiences, and managing transportation challenges.

CONCLUSIONS

To better engage young adults with early psychosis in care, including those from racial-ethnic minority groups, there is a need to design services that address the specific concerns of their everyday lives in the context of the initial hospitalization and posthospitalization period.

The Positive and Negative Experiences of Caregiving for Siblings of Young People with First Episode Psychosis

Background: The impact of first episode psychosis (FEP) upon parents’ experience of caregiving has been well-documented. However, the determinants and nature of this remain poorly understood in siblings. It is hypothesized that siblings of young people with FEP are also impacted by caregiving and burden. This study aimed to characterize the experience of caregiving for siblings of young people with FEP.

Method: Survey methodology was used to explore the experience of 157 siblings in the first 18 months of their brother or sister’s treatment for FEP. Participants reported on their appraisal of the negative and positive aspects of caregiving as measured by the Experience of Caregiving Inventory (ECI). Descriptive statistics were used to establish the results for the total sample as well as for gender and birth order differences. A series of multivariate regression analyses were conducted to determine the relationships between illness characteristics and siblings’ experience of caregiving.

Results: Older brothers reported the lowest scores for negative experiences in caregiving and younger sisters reported the highest. Negative experiences in caregiving resulted in less warmth within the sibling relationship and impacted negatively upon quality of life. When the young person with FEP had attempted suicide and/or been physically violent, siblings experienced more caregiver burden. Multivariate analysis showed that female gender was a significant factor in explaining the impact of illness related variables on the experience of caregiving.

Conclusion: Suicide attempts and a history of violence resulted in higher caregiving burden for siblings regardless of whether they lived with the young person experiencing FEP or not. Female siblings are at higher risk of negative experiences from caregiving resulting in a reduced quality of life and a changed sibling relationship. Suicide attempts and violence are indicators for intensive case management to improve outcomes for the individual with FEP which may in turn reduce the burden experienced by the sibling. Clinicians can use these findings to identify siblings, assertively intervene and provide increased psychological support, psychoeducation and practical problem solving to reduce the burden. The caregiving role that they already play for their ill brother or sister should be recognized.

Effectiveness of family interventions on psychological distress and expressed emotion in family members of individuals diagnosed with first-episode psychosis: a systematic review

BACKGROUND

A critical period for persons with first-episode psychosis is the first two years after diagnosis, when they are at high risk of suicide attempts, violent behaviors and substance abuse. This period also has a great impact on the psychological distress of family members, particularly caregivers who either provide care or live with ill family members. In addition, the families also report feelings of being overwhelmed when accessing service facilities at this critical point. These consequences impact on the affective tone/atmosphere in the family, also referred to as so-called expressed emotion. In addition, expressed emotion research has indicated that the family atmosphere contributes to recurrent psychosis and lengthy hospital stays for patients in the initial phase. Therefore, family interventions aimed at reducing psychological distress and improving expressed emotion in families during this critical time are very important. Modern research has yielded international evidence addressing these outcomes, but little is known about which interventions are the most effective. Therefore, this review aimed to evaluate the effectiveness of these interventions.

OBJECTIVES

The objective of this review was to examine the effectiveness of family interventions on psychological distress and expressed emotion in family members of persons with first-episode psychosis (FEP).

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Family members of persons with FEP and who had received treatment after being diagnosed within two years.

TYPES OF INTERVENTION(S)

Studies that examined interventions among family members of persons with FEP. Family interventions referred to any education, psychoeducation, communication, coping and problem-solving skills training and cognitive behavioral therapy that was provided to family members of persons with FEP.

OUTCOMES

Psychological distress and expressed emotions of those family members.

TYPES OF STUDIES

Randomized controlled trials, quasi-experimental studies, cohort studies and case-control studies.

SEARCH STRATEGY

The preliminary search was conducted in MEDLINE and CINAHL with keywords containing the title, abstract and subject description analysis as the first identification of related studies. An extensive search was conducted in other databases including ProQuest Dissertations and Theses, ScienceDirect, Scopus, PsychINFO, ThaiLIS and Thai National research databases. In addition, searches of reference lists and other manual searches were undertaken.

METHODOLOGICAL QUALITY

Studies were critically appraised by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute.

DATA EXTRACTION

Data were extracted using the standardized data extraction tools from the Joanna Briggs Institute. The mean score and standard deviation (SD) were extracted for targets outcomes relating to psychological distress and expressed emotion.

DATA SYNTHESIS

Quantitative data could not be pooled due to the heterogeneity of the included studies. Data were synthesized based on the individual results from the three included studies and have been presented in a narrative format accompanied with tabulated data.

RESULTS

Data synthesis of the three individual studies indicated that there were no statistically significant interventions that address psychological distress and expressed emotion in family members who live with and care for persons with FEP. There is insufficient evidence available to evaluate the effect sizes for pooled outcomes.

CONCLUSION

Based on the results of this review, there is insufficient evidence to validate the effectiveness of family interventions on psychological distress and expressed emotion in family members who live with and care for persons with FEP. In addition, based on the individual primary studies, the implications for practice should be carefully considered.

What factors influence successful recruitment of siblings of individuals with first episode psychosis to e-health interventions? A qualitative study

Background

Recruitment to clinical research studies can prove complex. This is particularly true of mental health research, given factors such as confidentiality, capacity and consent, or when attempting to recruit family members as opposed to service users themselves.

Aim

This study investigated the challenges experienced and strategies employed in the recruitment of siblings of people with first episode psychosis using Early Intervention in Psychosis Services (EIPS) in England.

Methods

As part of a randomized controlled trial (RCT) of an e‐health intervention for siblings, we conducted a process evaluation study whereby semistructured interview was undertaken with clinical and research staff involved in recruitment of siblings. Data were analysed thematically.

Results

Twelve participants from six EIPS were interviewed. Data analysis revealed seven key themes: (i) limited comprehensive family data available; (ii) data governance and consent issues; (iii) organizational factors; (iv) convoluted recruitment methods; (v) concerns about service users' opinions; (vi) fluidity in siblings' needs and expectations; and (vii) strategies to enhance recruitment.

Conclusions

Recruitment challenges identified in this study concerned administrative, organizational, process and attitudinal issues. These are similar to other studies recruiting mental health service users as well as family members. Failure to recruit to target implies that studies are underpowered to detect potential statistically or clinically meaningful changes. Future studies should establish how best to enhance family inclusiveness in clinical practice and research.

Wellbeing, mental health knowledge and caregiving experiences of siblings of people with psychosis, compared to their peers and parents: an exploratory study

PURPOSE

The wellbeing and caregiving experiences of family carers supporting people with psychosis has garnered increasing interest. Evidence indicates that the burden of caregiving can adversely impact on parents' wellbeing, few studies have investigated whether this is also the case for siblings, who often take on caregiving responsibilities. This exploratory study investigated the wellbeing, mental health knowledge, and appraisals of caregiving in siblings of individuals with psychosis.

METHOD

Using a cross-sectional design, 90 siblings completed three validated questionnaires: Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS), Mental Health Knowledge Schedule (MAKS), and Experience of Caregiving Inventory (ECI). Data obtained were compared to general population norms and parent-carers' scores. Multi-variable regression analyses were conducted to examine relationships between questionnaire scores and demographic characteristics including age, sex, birth order, marital status, accommodation and educational level.

RESULTS

Siblings, especially sisters, had significantly poorer mental wellbeing, compared to normative scores. Conversely, they had better mental health knowledge. Siblings and parent-carers had comparable high levels of negative appraisals of caregiving experiences, but siblings reported more satisfaction with personal experiences and relationships. Education level was a significant predictor for better mental health knowledge; there were no other relationships between siblings' demographic factors and outcomes.

CONCLUSION

Study findings suggest that siblings have overlapping as well as distinct needs, compared to parent-carers. Further research is required to better understand siblings' experiences so as to inform development of targeted interventions that enhance wellbeing and caregiving capacity.

The experience of adolescent inpatient care and the anticipated transition to the community: Young people's perspectives

This study explored adolescents' perspectives of inpatient mental health care, focussing on aspects of the inpatient environment they anticipated would help or hinder their transition back home. Semi-structured interviews were conducted with 12 adolescent inpatients; transcripts were analysed thematically. Participants experienced inpatient treatment as offering a mix of benefits (e.g., supportive relationships) and drawbacks (e.g., living in a "fake world"). They anticipated the transition home as providing opportunities for personal growth and consolidation of new coping skills, but also posing challenges concerning re-entering the "real world" after the experience of being "wrapped in cotton wool". Self-determination theory and attachment theory offer two potential frameworks for understanding these opportunities and challenges. Inpatient care has the potential to foster key mechanisms for adaptive development, creating a platform for developing positive future behaviours. Community teams should work closely with inpatient units to support the generalisation of the young person's newly acquired coping skills.

Assessing the needs of siblings of persons with schizophrenia: A qualitative study from India

There is a lack of studies on siblings of persons with schizophrenia (SOPS) in Asia. This study aims to explore the needs of SOPS in India. 15 SOPS participated in this qualitative explorative study. All the interviews were audio recorded and later transcribed. Data analysis was carried out using General Inductive Approach. Five themes emerged from the data: managing illness or socio-occupational functioning; follow up services; informational needs; personal needs; and miscellaneous needs. SOPS in India have some distinctive needs. Identifying these needs might help in developing and designing specific psychosocial interventions for better management.

Psychoeducation for siblings of people with severe mental illness

BACKGROUND

Many people with severe mental illness (SMI) have siblings. Siblings are often both natural agents to promote service users' recovery and vulnerable to mental ill health due to the negative impact of psychosis within the family. Despite a wealth of research evidence supporting the effectiveness of psychoeducation for service users with SMI and their family members, in reducing relapse and promoting compliance with treatment, siblings remain relatively invisible in clinical service settings as well as in research studies. If psychoeducational interventions target siblings and improve siblings' knowledge, coping with caring and overall wellbeing, they could potentially provide a cost-effective option for supporting siblings with resulting benefits for service users' outcomes.

OBJECTIVES

To assess the effectiveness of psychoeducation compared with usual care or any other intervention in promoting wellbeing and reducing distress of siblings of people affected by SMI.The secondary objective was, if possible, to determine which type of psychoeducation is most effective.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register and screened the reference lists of relevant reports and reviews (12th November 2013). We contacted trial authors for unpublished and specific data on siblings' outcomes.

SELECTION CRITERIA

All relevant randomised controlled trials focusing on psychoeducational interventions targeting siblings of all ages (on their own or amongst other family members including service users) of individuals with SMI, using any means and formats of delivery, i.e. individual (family), groups, computer-based.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the abstracts and extracted data and two other authors independently checked the screening and extraction process. We contacted authors of trials to ascertain siblings' participation in the trials and seek sibling-specific data in those studies where siblings' data were grouped together with other participants' (most commonly other family members'/carers') outcomes. We calculated the risk difference (RD), its 95% confidence interval (CI) on an intention-to-treat basis. We presented continuous data using the mean difference statistic (MD) and 95% CIs. We assessed risk of bias for the included study and rated quality of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE).

MAIN RESULTS

We found 14 studies that included siblings amongst other family members in receipt of psychoeducational interventions. However, we were only able to include one small trial with relevant and available data (n = 9 siblings out of n = 84 family member/carer-participants) comparing psychoeducational intervention with standard care in a community care setting, over a duration of 21 months. There was insufficient evidence to determine the effects of psychoeducational interventions compared with standard care on 'siblings' quality of life' (n = 9, MD score 3.80 95% CI -0.26 to 7.86, low quality of evidence), coping with (family) burden (n = 9, MD -8.80 95% CI -15.22 to -2.34, low quality of evidence). No sibling left the study early by one year (n = 9, RD 0.00 CI -0.34 to 0.34, low quality of evidence). Low quality and insufficient evidence meant we were unable to determine the effects of psychoeducational interventions compared with standard care on service users' global mental state (n = 9, MD -0.60 CI -3.54 to 2.38, low quality of evidence), their frequency of re-hospitalisation (n = 9, MD -0.70 CI -2.46 to 1.06, low quality of evidence) or duration of inpatient stay (n = 9, MD -2.60 CI -6.34 to 1.14, low quality of evidence), whether their siblings received psychoeducation or not. No study data were available to address the other primary outcomes: 'siblings' psychosocial wellbeing', 'siblings' distress' and adverse effects.

AUTHORS' CONCLUSIONS

Most studies evaluating psychoeducational interventions recruited siblings along with other family members. However, the proportion of siblings in these studies was low and outcomes for siblings were not reported independently from those of other types of family members. Indeed, only data from one study with nine siblings were available for the review. The limited study data we obtained provides no clear good quality evidence to indicate psychoeducation is beneficial for siblings' wellbeing or for clinical outcomes of people affected by SMI. More randomised studies are justified and needed to understand the role of psychoeducation in addressing siblings' needs for information and support.

Associations between stereotype awareness, childhood trauma and psychopathology: a study in people with psychosis, their siblings and controls

Introduction

Stereotype awareness—or an individual’s perception of the degree to which negative beliefs or stereotypes are held by the public—is an important factor mediating public stigma, self-stigma and their negative consequences. Research is required to assess how individuals become more sensitive to perceive stereotypes, pointing the way to therapeutic options to reduce its negative effects and increase stigma resilience. Because perception and interpretation can be guided by belief systems, and childhood trauma (CT) is reported to impact such beliefs, CT is explored in relation to stereotype awareness (SA) in persons with psychosis, their siblings and controls.

Method

Data from the GROUP project (Genetic Risk and Outcome of Psychosis) were analyzed. SA was measured by devaluation scales which assess a respondent’s perception of the degree to which stereotypes about people with mental illness and about their families are held by the public. CT was measured using the Childhood Trauma Questionnaire (short form).

Results

In patients, symptoms of disorganization and emotional distress were associated with SA about people with mental illness. In siblings, schizotypal features were associated with both types of SA (more schizotypy = more SA). In both patients and siblings, CT was associated with both types of SA (more CT = more SA), independent of symptoms (patients) or schizotypy (siblings).

Conclusion

CT in people with psychosis and their siblings may sensitize to SA. Thus, CT may not only impact on risk for illness onset, it may also increase SA associated with mental illness, potentially interfering with the recovery process. CT-induced SA may indicate a heightened sensitivity to threat, which may also impact psychopathology.

Forgotten family members: the importance of siblings in early psychosis

OBJECTIVE

This paper reviews the evidence on the significance of sibling inclusion in family interventions and support during early psychosis.

METHOD

This narrative review presents the current research related to the importance of family work during early psychosis, the needs and developmental significance of siblings during adolescence and early adulthood, the protective effects of sibling relationships, and the characteristics of early psychosis relevant to the sibling experience. It will also review the evidence of the sibling experience in chronic physical illness and disability, as well as long-term psychotic illness.

CONCLUSIONS

Despite the evidence that working with families is important during early psychosis, siblings have been largely ignored. Siblings are an important reciprocal relationship of long duration. They play an important role in development during adolescence and early adulthood. These relationships may be an underutilized protective factor due to their inherent benefits and social support. Developmental theories imply that early psychosis could negatively impact the sibling relationship and their quality of life, effecting personality development and health outcomes. The evidence shows that adolescent physical illness or disability has a significantly negative impact on the sibling's quality of life and increases the risk for the onset of mental health issues. Long-term psychotic illness also results in negative experiences for siblings. Current evidence shows that siblings in early psychosis experience psychological distress and changes in functional performance. Further research using standard measures is required to understand the impact early psychosis has on the sibling relationship and their quality of life.

The impact of first episode psychosis on sibling quality of life

PURPOSE

The adverse impact of first episode psychosis (FEP) upon parents' quality of life (QoL) has been well documented. However, the determinants and levels of QoL remain poorly understood in siblings of young people experiencing FEP. This study aimed to characterise and establish the predictors of QoL for siblings of young people with FEP.

METHOD

Survey methodology was used to examine the experience of 157 siblings in the first 18 months of their brother or sister's treatment for FEP. The World Health Organisation Quality of Life Scale-Bref (WHOQOL-Bref) was used to assess siblings' QoL. A series of multivariate regression analyses were conducted to determine the relationships between illness characteristics and siblings' QoL.

RESULTS

Younger sisters reported the lowest satisfaction of QoL. Older brothers were the most satisfied. When the young person with FEP had attempted suicide and/or had been physically violent, siblings reported less satisfaction in all domains of QoL. Living with the ill brother or sister resulted in less satisfaction in the social domain. Multivariate analysis showed that female gender was a significant factor in explaining the impact of illness-related variables on QoL, particularly suicide attempts.

CONCLUSION

Suicide attempts and a history of violence impacted negatively on all four domains of QoL. Female siblings are at higher risk of reduced QoL and may be particularly vulnerable to the effects of suicide attempts and violence. These findings have significant implications for early, targeted interventions for this vulnerable group.

The family roles of siblings of people diagnosed with a mental disorder: heroes and lost children

In order to cope with the diagnosis of mental illness in a family member, siblings may be forced to adjust their roles in the family. Taking into account the crucial role that some siblings play in caregiving for the mentally ill especially when the parents are no longer available, it is imperative to develop awareness of their unique needs and address them. Thirty-three adult siblings of people diagnosed with a mental disorder completed the Role Behaviour Inventory (RBI) and a general questionnaire including open-ended questions regarding the roles they played in their families of origin. Findings from the inventory and general questionnaire suggest that the well siblings score higher on two roles, the Hero and Lost Child, and lower on the Mascot and Scapegoat roles relative to a comparison group (N = 33). Being a sibling caregiver emerged as a risk factor to assume certain dysfunctional roles in the family. Implications for future research and therapy are discussed.

The E Sibling Project - exploratory randomised controlled trial of an online multi-component psychoeducational intervention for siblings of individuals with first episode psychosis

BACKGROUND

Siblings of individuals with first episode psychosis are natural partners to promote service users' recovery and are themselves vulnerable to mental ill health due to the negative impact of psychosis within the family. This study aims to develop and undertake a preliminary evaluation of the efficacy of an online multi-component psychoeducational intervention for siblings of individuals with first episode psychosis. The impetus for the intervention arose from siblings' expressed needs for peer support and information on psychosis, coping and management strategies for common symptoms and ways to promote recovery.

METHODS/DESIGN

The project design draws on the Medical Research Council framework for the design and evaluation of complex interventions. Mixed methods comprising collection of qualitative focus group data, systematic review and expert advisory group consultation are used to develop the theoretical basis for and design of the intervention. This protocol focuses on the modelling and piloting phase which uses a randomised controlled trial with factorial design to test the efficacy of the intervention. Outcome data on participants' mental wellbeing, knowledge, perceived self-efficacy and experiences of caregiving will be assessed at baseline, at end of the intervention (10 weeks later) and at 10 week follow-up. In addition, a post-intervention semi-structured interview with 20% of the participants will explore their experiences and acceptability of the intervention.

DISCUSSION

This multi-component online psychoeducational intervention aims to enhance siblings' knowledge about psychosis and their coping capacity, thus potentially improving their own mental wellbeing and promoting their contribution to service users' recovery. The factorial design randomised controlled trial with a supplementary process evaluation using semi-structured interviews and usage-monitoring will collect preliminary evidence of efficacy, feasibility and acceptability, as well as feedback about the barriers and strategies to using such an innovative resource. The RCT will provide data for estimating the likely effect size of the intervention on outcomes for siblings and inform the development of a definitive future trial.

TRIAL REGISTRATION

Trial registration: ISRCTN01416694.

Drawing the line: a case study of ambivalence in sibling support for adults with complex needs

The purpose of this article is to illuminate the dynamics of sibling group support when one sibling has complex needs accompanied by difficult behaviors. A case study of sibling support for a twenty-year-old woman with a disability, a mental health issue, and addictions, drawn from the perspectives of her full brother, her half-brother, and their mother, is presented. The brothers express ambivalence between devotion to supporting their sister and limits to the support they feel able to provide. The limits the brothers place on their support allow them to adhere to their values, preserve their energy and, ultimately, sustain their ability to provide support.

Understanding the experiences and service needs of siblings of individuals with first-episode psychosis: a phenomenological study

BACKGROUND

Despite recent focus on developing family-inclusive services to meet the needs of young people with first-episode psychosis, the needs of their siblings are often overlooked.

AIMS

This study explored the experiences and needs of siblings of young adults with first-episode psychosis receiving support from two Early Intervention in Psychosis Services in South-East England.

METHODS

Thirty-one siblings aged 11-35 years, were given a semi-structured interview to gather their perspectives and accounts of their lived experiences. The resultant rich qualitative data was analysed using responsive-reader and framework methods.

RESULTS

Six themes were identified: siblings' roles and involvement; emotions; impact on relationships; coping patterns; resilience; and siblings' service needs.

CONCLUSION

All participants had been greatly affected by the onset of the psychosis in their brother or sister. Most siblings did not identify themselves as carers, although most played a significant part in their brother's or sister's life. Participants wanted dynamic, robust and accessible services, especially information and peer support to meet their needs.

First-time primary caregivers' experience of caring for young adults with first-episode psychosis

Becoming a career is associated with physical, emotional, and financial hardship, with caregivers often experiencing a maelstrom of emotions as they struggle to understand what has happened to their loved one. While the burden of caring for young people with first-episode psychosis (FEP) has been well documented, much less is known about how carers develop the strength and resilience to continue caring. This qualitative study aimed to understand the experience of 20 first-time primary caregivers of young adults with FEP. Most caregivers were female (85%, n = 17) and parents (85%, n = 17). The average length of involvement as a caregiver at an FEP service was 14.5 months. Six main themes were identified in the data, highlighting the carers' experience in supporting young adults with FEP. Caregiving is a burdensome responsibility and is characterized as a roller coaster and unpredictable experience. Caregivers often feel responsible for the young person's illness; however, eventually most come to terms with the changes that have occurred in the young person with FEP. As a consequence of the illness, the relationship between caregiver and care recipient frequently becomes closer and deeper, although it is important that they both maintain hope for the future. These findings provide important insights into the experiences of first-time caregivers of young people with FEP, with direct implications for improving the information and support given to caregivers by FEP services, as well as the development of interventions that effectively address the unique challenges caregivers face following the onset of FEP.

The efficacy of a cognitively orientated carers group in an early intervention in psychosis service--a pilot study

A significant amount of evidence has demonstrated that families and carers play an important role in an individual's recovery from a first episode of psychosis (FEP) and can significantly reduce relapse rates. This, in addition to the fact that caring for an individual experiencing their FEP can be incredibly stressful, suggests that the development of appropriate support for carers must be an integral part of any Early Intervention in Psychosis Service (EIPS). This study examines the efficacy of a closed structured group designed for carers of individuals experiencing their FEP based in Southampton city. A 12-session cognitively orientated group programme covering a range of areas was attended by 18 carers over a 6-month period. Following the group, a significant decrease was found in the carer's negative appraisals of the impact of psychosis, feelings of burden, depression and anxiety rates as measured by the Experience of Caregiving Inventory (ECI), Caregiver Burden Inventory (CBI), Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI). A significant positive correlation was also found between carer's negative appraisals and their anxiety and depression rates, although further research is needed to clarify the causality of this relationship.

Perceptions and needs of parents during a young adult's first psychiatric hospitalization: "we're all on this little island and we're going to drown real soon"

A young person's first psychiatric hospitalization can present a crisis for the family. This initial contact with the mental health care system and health care providers, whether positive or negative, has the potential to set the foundation for all future interactions. The purpose of this study was to examine the impact of a young person's first hospitalization on his or her parents and to determine the parents' perspectives on their own emotional and practical support needs. Ten parents (nine mothers and one father) of a young person aged 18 to 25 were recruited through local support groups and by snowball sampling. Based on Aguilera and Messick's (1986) crisis theory, participants were asked about their perception of the event, coping methods they used, and support systems they engaged while their adult child was hospitalized. Six themes were identified: feeling relief about receiving a diagnosis; shock and disbelief associated with the diagnosis of a mental illness; isolation associated with the stigma of mental illness; feeling excluded during the discharge process; and grieving for the loss associated with an altered future. The results revealed that participants received their support from family, friends, and support groups and did not find mental health care providers to be helpful or supportive. The participants provided recommendations for those who work with families experiencing the crisis of a first psychiatric hospitalization.

A descriptive review of qualitative studies in first episode psychosis

AIM

The aim of this paper is to provide a descriptive review of published qualitative research studies on first episode psychosis (FEP).

METHODS

A review was undertaken to describe the findings of qualitative studies in early psychosis. Keyword searches in Medline, CINAHL, ASSIA, PsychINFO databases, as well as manual searches of other relevant journals and reference lists of primary papers, were conducted.

RESULTS

Thirty-one qualitative papers (representing 27 discrete studies) were identified. The majority reported research concerning young people based in community settings. The research studies were organized according to the following generic social processes: (i) achieving identity; (ii) acquiring perspectives; (iii) doing activity; and, (iv) experiencing relationships. The papers reviewed are based on first-person accounts obtained from individuals who have experienced FEP, their family members and service providers.

CONCLUSION

This descriptive review contributes to our understanding of the complex social processes of achieving identity, acquiring perspectives, doing activities and developing relationships as experienced by young people and the significant others in their world. The cumulative findings highlight the contextually rich and detailed information made possible through qualitative studies of FEP. They begin to account for the active engagement of individuals affected by psychosis in making sense of their experience and suggest that this experience should be understood from within young people's own framework of meaning.