Family Psychoeducation for Serious Mental Illness

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Clinical Trials.

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Major depressive disorder MDD is a common disorder, widely distributed throughout the population, and usually associated with substantial symptoms and role impairment. The prevalence of cases of lifetime MDD was Treatment failure results in a low recovery rate and frequent relapses [ 5 ]. MDD can also cause severe suffering for family members of the patient in multiple areas including a higher level of divorce [ 8 ] and severe financial strain [ 9 ].

Fadden et al. Relatives of patients with depression found some of the behaviors of the patients to be difficult to bear, and the relatives had negative consequences such as grief, withdrawal, and worrying, which commonly caused problems. However, few relatives know how to deal with the difficult behavior of patients [ 10 ]. Therefore, the relatives felt dissatisfaction in that the patient could control those behaviors [ 10 ]. Jacob et al. Taken together, these findings suggest that living with a patient with MDD is a source of strain and emotional distress for relatives. The difficultness of maintaining functioning family relationships for example the patient may have marital problems, poorer communication, and no problem-solving skills was associated with poorer long-term outcome for the depression [ 15 , 16 ].

Rounsaville et al. Several studies reported that the quality of family functioning was associated with the relapse rate. Although Hayhurst et al. These studies suggest the need for a more family-oriented approach in the treatment of MDD. However, a review conducted by Henken et al. However it remains unclear how effective this intervention is in comparison with other interventions such as group intervention, individual cognitive intervention, and behavioral intervention.

In spite of the lack of high-quality evidence in this field, family therapy is already a widely-used intervention for the treatment of depression [ 24 ]. Family psychoeducation is recognized as part of the optimal treatment for patients with a psychotic disorder [ 25 , 26 ].

Protocols ARTICLE

This intervention has been shown to reduce the rates of relapse and hospitalization among individuals with psychotic disorders and is recognized as an evidenced-based treatment for psychotic disorders [ 27 ]. Two randomized controlled trials have found that family psychoeducation is effective in enhancing the course of MDD [ 28 , 29 ].

In a study of adolescents with MDD, patients in the group who received family psychoeducation showed greater improvements in social functioning and adolescent-parent relationship than the control group [ 28 ]. Among patients with MDD in partial or full remission, patients who were treated with the family psychoeducation had a significantly lower relapse rate than patients who were in the control group [ 29 ].

Additionally, although MDD can easily become chronic, there has been no intervention study for the families of patients with MDD lasting more than one year. In the present study, we perform a randomized controlled trial to examine the effectiveness of family psychoeducation in improving the mental health of the relatives of patients with MDD lasting more than one year. This randomized controlled trial will be conducted in patients with MDD who will be allocated to one of two arms: family psychoeducation in addition to treatment-as-usual for the patients, and treatment-as-usual.

Treatment-as-usual consists of consultation administered by a physician and counseling by a nurse. We defined mental health as the state of health of the mind and that when the mental health of relatives was in an unhealthy state, the person suffered from mental disorder such as depressive and anxiety disorder. Participant flow diagram. The target population will be patients with MDD lasting more than one year and their relatives fathers, mothers, husbands, wives, daughters, and sons of patients.

Exclusion criteria will be: patients who undergo electroconvulsive therapy ECT during the investigation period and patients who are at serious suicidal risk. All participants will provide written informed consent after the purpose and procedures of the study are explained.

This study is registered at ClinicalTrials. We will provide eligible patients with an ID number and then ask patients and their relatives to provide informed consent and complete a baseline assessment Assessment I. After providing informed consent and completing the baseline assessment, participants will be randomized. Assessment will occur at baseline, before randomization, and at 8, 16, and Participants will be randomly allocated to one of the two groups with equal probability. This random assignment will be made in a ratio.

An independent statistician will generate the random allocation sequences by a computer using minimization [ 30 ], and stratify the relatives according to the severity of mental state K6 score of 5 or more, or less than 5. Allocation sequences will be kept centrally and the allocation will be provided by facsimile to us. The randomization schedule is not available to anyone except the statistician.


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The multifamily psychoeducational program will consist of four sessions. Each of the four multifamily psychoeducational program groups will consist of the relatives of approximately four patients. The staff will consist of one or two psychiatrists, one or two nurses, one pharmacologist, and one social worker. The teaching materials for the relatives of the patients are a videotape produced by the Department of Neuropsychiatry, Kochi Medical School [ 34 ], including the videotaped interview of the experience of a patient with MDD, an explanation of the cause of MDD using computer graphics images of synapses and neurotransmitters, and a booklet developed by our department.

At the first session we will give the participants information on the causes and symptoms of major depression, at the second session we will provide information on drug treatment, at the third session we will provide information on community resources, and at the fourth session we will provide guidelines for families caring for patients. In the group therapy sessions, the participants will be encouraged to give a narrative of their subjective experience in taking care of the MDD patient.


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Each session will last approximately two hours. The groups will meet once every two weeks over the course of six weeks. The patients in both the intervention and control groups will receive standard outpatient or inpatient treatment administered by physicians. Outpatient treatment consists of evaluation of psychiatric symptoms, antidepressant pharmacotherapy, and supportive psychotherapy on a bi-weekly or-four-weekly basis. Inpatient treatment consists of sufficient rest for the patient, evaluation of psychiatric symptoms, antidepressant pharmacotherapy, and supportive psychotherapy.

All of the participants will receive some case management. Family treatment in the control group consists of one counseling session administered by a nurse. This counseling consists of listening to any issues or problems and providing any information that is ask for. The information requested is usually regarding their communication, relapses, and how to take their drugs. All staff except one pharmacologist had participated in intensive training which consisted of more than eleven hours using the treatment manual of the JNPF [ 33 ].

The raters will each be trained and certified as a family psychoeducation instructor by the JNPF. The participants of this study will not be individuals with a mental disease but will be among the general population, and our previous study showed that the K6 was excellent for measuring changes in the mental health of relatives of MDD patients [ 36 ]. Two independent validation studies found the K6 to have an area under the receiver operating characteristic curve between 0.

The Japanese version of the K6 questionnaire showed excellent efficacy in screening for anxiety and mood disorders in the Japanese general population, with an area under the receiver operating characteristic curve of 0. In the Czech Republic, out of mental health care departments outpatient, inpatient, and community services and 60 social services departments, only 46 departments provide some type of psychoeducation for schizophrenia—16 of those provide family psychoeducation for patients and relatives and 1 provides psychoeducation for relatives only [ 21 ].

What are some possible barriers to the provision of psychoeducation? Certainly, lack of adequate reimbursement for such services is a serious obstacle.

Serious Mental Illness: How Can We Promote Public Health and Public Safety?

Moreover, we speculate that the biggest hurdle in implementation and use of psychoeducation is possibly the lack of knowledge and skills in delivering it due to a lack of training opportunities. While information about medication in the treatment and management of serious mental illness is taught in all undergraduate and psychiatry residency programs worldwide, perhaps information on delivery skills and training on how to conduct psychoeducational interventions are not so consistently taught.

If a patient had diabetes or heart disease, it would be expected that the nature, course, and treatment of the illness would be explained. Is there a difference in psychiatry?

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It should be noted that it is a core competency in psychopharmacology to provide detailed information about the indications, use, risks, and benefits of medications to all patients. Yet the diagnosis, prognosis, and impact of the underlying disorder may not be so formally discussed. Although time may serve as a barrier in some settings, psychoeducation is a critical first element in the provision of a comprehensive treatment plan and should not be neglected.

Also, psychoeducation is likely to save time in the long term by reducing relapses and improving patient and family engagement in care.

Mindfulness-Based Family Psychoeducation Intervention for Early Psychosis

In order to provide psychoeducation, clinicians should be able to teach patients and their families or primary caretakers about early warning signs and management of recurrence. Based on our experience with patients suffering from schizophrenia, these topics can, at times, provoke anxiety, which may lead to temporary worsening of illness in patients with incomplete or fragile remission. Dealing with the frustration of relatives is another important skill of family psychoeducation.

The clinician providing psychoeducation must be ready to deal with emotions and anger and must be able to keep boundaries and set limits to preserve a constructive and therapeutic atmosphere e.

Time should be set aside for this purpose, and an effort should be made to ensure that the material can be recalled and understood. We believe that lack of these skills is an obstacle to providing good family psychoeducation. We also believe that part of the skill set in psychoeducation is providing ample time for questions about the illness and its treatment. Further, it must be determined if, after psychoeducation, the patients and family really understand what was discussed about the illness.

Asking patients and their families to recount what they heard provides a window into appreciating their accurate appraisal and understanding of the disorder.

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Psychoeducation educators should therefore be experienced clinicians who are able to present their knowledge in a comprehensible way and should also be skilled moderators to ensure interactivity. First, psychoeducation should take account of the whole person and build on strengths and resilience [ 25 ]. Second, psychoeducation crucially involves the ability to deal with emotional aspects, as the patient—often at a very young age—suffers from a severe illness that interferes with overall life plans, goals, and dreams. To accept this reality and adapt to the illness, a patient must not only receive proper information but also receive emotional support and guidance.

In the case of youth who sustain a psychiatric disorder, the clinician needs to communicate in a manner consistent with the developmental level of the child or adolescent. And, of course, the parents or caregivers need detailed information, including information about how to reduce stress in the household, as they are the most important treatment resource that should not be ignored [ 7 , 8 ]. Third, psychoeducation must include behavioral interventions, notably promotion of healthy activities in daily living such as good sleep habits, nutrition, exercise, and support from friends.

Further, many online sites provide poor, biased information about psychiatric disorders, and patients may seek additional information through online searches. Clinicians should be prepared to guide patients and families to trusted online resources for additional information. Psychoeducation should be part of the management of all mental disorders and should be offered in individual or group format.

Basic curricula should be well defined and manualized, covering four major areas: a information about the illness, b recognition and management of early warning signs, c lifestyle management, including how to ameliorate stress in families and household groups, and d importance of involvement of relatives and primary care providers. The curriculum should emphasize that information delivery should respect neurocognitive or other impairments and should include, whenever applicable, graphic models or visualizations.

The curriculum should also stress the importance of interactivity and active involvement of all participants, regardless of the format of psychoeducation. In psychoeducation, family members and caregivers should participate whenever possible and should be provided with discrete disease-specific modules, covering high expressed emotions recognition and adaptive communication skills training.

Unfortunately, psychoeducation as an intervention is not consistently included in medical training curricula nor required as a skill among core competencies. The closest requirement in the U. Psychoeducation has proved to be highly relevant for many diagnoses both in psychiatry and in other medical speciailties. Many clinicians who have had the chance to provide psychoeducation or who have met with patients that participated in psychoeducational programs already call for its widespread implementation [ 29 ].

Psychoeducation is not just a one-way delivery of information from clinicians to patients and their families; as an interactive process, it allows clinicians to receive valuable insights into problems connected with mental illness, and these insights may be different from what is learned from usual doctor-patient contact.