Family interventions for schizophrenia in Italy: randomized controlled trial

  • Giuseppe Carrà
  • Cristina Montomoli
  • Massimo Clerici
  • Carlo Lorenzo Cazzullo
ORIGINAL PAPER

Abstract

Objective

To evaluate the effectiveness of multiple group family treatment for Schizophrenia.

Method

Relatives were randomly provided with an informative programme (n = 50), or allocated to receive an additional support programme (n = 26). Patients did not attend the programme to overcome cultural and organizational implementation barriers. The 12 and 24 months clinical and family outcomes were assessed.

Results

Patients’ compliance with standard care was greater at 12 months in the more intensive behavioural management group over a control group receiving treatment as usual (TAU) (n = 25). A reduction in levels of expressed emotion (EE), significantly more frequent in those receiving the additional support programme than just the informative, occurred after treatment completion. Other clinical and family outcomes did not differ. However, treatment benefits declined at 24 months, when baseline high EE was again predictive of patient’s admission and relatives were more vulnerable to objective burden. Baseline illness severity variables predicted a number of medium and long-term poor clinical outcomes.

Conclusions

Although family psychoeducation has been tested in a wide range of Anglo-Saxon settings, there remains need to assess outcomes more internationally. Effective family interventions for people with schizophrenia probably require continued administration of key-elements or ongoing informal support to deal with the vicissitudes of illnesses.

Keywords

schizophrenia psychoeducation family expressed emotion randomized controlled trials 

References

  1. American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders, 4th edn. American Psychiatric Association, Washington, DCGoogle Scholar
  2. Baronet AM (1999) Factors associated with caregiver burden in mental illness: a critical review of the research literature. Clin Psychol Rev 19:819–841PubMedCrossRefGoogle Scholar
  3. Bebbington P, Kuipers L (1994a) The predictive utility of expressed emotion in schizophrenia: an aggregate analysis. Psychol Med 24:707–718Google Scholar
  4. Bebbington P, Kuipers L (1994b) The clinical utility of expressed emotion in schizophrenia. Acta Psychiatr Scand Suppl 382:46–53Google Scholar
  5. Bertrando P, Beltz J, Bressi C, Clerici M, Farma T, Invernizzi G, Cazzullo CL (1992) Expressed emotion and schizophrenia in Italy. A study of an urban population. Br J Psychiatry 161:223–229PubMedGoogle Scholar
  6. Burland J (1998) Family-to-family: a trauma and recovery model of family education. New Dir Ment Health Serv 77:33–44PubMedGoogle Scholar
  7. Bustillo J, Lauriello J, Horan W, Keith S (2001) The psychosocial treatment of schizophrenia: an update. Am J Psychiatry 158:163–175PubMedCrossRefGoogle Scholar
  8. Butzlaff RL, Hooley JM (1998) Expressed emotion and psychiatric relapse: a meta-analysis. Arch Gen Psychiatry 55:547–552PubMedCrossRefGoogle Scholar
  9. Cazzullo CL, Bertrando P, Clerici M, Bressi C, Da Ponte C, Albertini E (1989) The efficacy of an information group intervention on relatives of schizophrenics. Int J Soc Psychiatry 35:313–323PubMedGoogle Scholar
  10. Cazzullo CL, Clerici M, Bertrando P (1994) Future strategies in family research and intervention. Integr Psychiatry 10:20–23Google Scholar
  11. Chien WT, Chan SW (2004) One-year follow-up of a multiple-family-group intervention for Chinese families of patients with schizophrenia. Psychiatr Serv 55:1276–1284PubMedCrossRefGoogle Scholar
  12. De Girolamo G, Cozza M (2000) The Italian Psychiatric Reform. A 20-Year Perspective. Int J Law Psychiatry 23:197–214PubMedCrossRefGoogle Scholar
  13. Dixon L, Adams C, Lucksted A (2000) Update on family psychoeducation for schizophrenia. Schizophr Bull 26:5–20PubMedGoogle Scholar
  14. Dixon L, McFarlane WR, Lefley H, Lucksted A, Cohen M, Falloon I, Mueser K, Miklowitz D, Solomon P, Sondheimer D (2001) Evidence-based practices for services to families of people with psychiatric disabilities. Psychiatr Serv 52:903–910PubMedCrossRefGoogle Scholar
  15. Endicott J, Spitzer RL, Fleiss JL, Cohen J (1976) The Global Assessment Scale: a procedure for measuring the overall severity of psychiatric disturbance. Arch Gen Psychiatry 33:766–771PubMedGoogle Scholar
  16. Grella CE, Grusky O (1989) Families of the seriously mentally ill and their satisfaction with services. Hosp Commun Psychiatry 40:831–835Google Scholar
  17. Hofer A, Rettenbacher MA, Widschwendter ChG, Kemmler G, Hummer M, Fleischhacker WW (2006) Correlates of subjective and functional outcomes in outpatient clinic attendees with schizophrenia and schizoaffective disorder. Eur Arch Psychiatry Clin Neurosci 256:246–255PubMedCrossRefGoogle Scholar
  18. Hornung WP, Feldmann R, Klingberg S, Buchkremer G, Reker T (1999) Long-term effects of a psychoeducational psychotherapeutic intervention for schizophrenic outpatients and their key-persons-results of a five-year follow-up. Eur Arch Psychiatry Clin Neurosci 249:162–167PubMedCrossRefGoogle Scholar
  19. Kopelowicz A, Zarate R, Gonzalez V, Lopez SR, Ortega P, Obregon N, Mintz J (2002) Evaluation of expressed emotion in schizophrenia: a comparison of Caucasians and Mexican-Americans. Schizophr Res 55:179–186PubMedCrossRefGoogle Scholar
  20. Leff J, Berkowitz R, Shavit N, Strachan A, Glass L, Vaughn C (1989) A trial of family therapy v, a relatives group for schizophrenia. Br J Psychiatry 154:58–66PubMedGoogle Scholar
  21. Leff J, Vaughn C (1985) Expressed emotion in families: its significance for mental illness. Guilford, New YorkGoogle Scholar
  22. Lefley H (2001) Impact of mental illness on families and carers. In: Thornicroft G, Szmukler G (eds) Textbook of community psychiatry. Oxford University Press, London, pp 141–154Google Scholar
  23. Liberman DB, Liberman RP (2003) Rehab rounds: Involving families in rehabilitation through behavioral family management. Psychiatr Serv 54:633–635PubMedCrossRefGoogle Scholar
  24. Linszen D, Dingemans P, Van Der Does J, Nugter A, Scholte P, Lenior R, Goldstein M (1996) Treatment, expressed emotion and relapse in recent onset schizophrenic disorders. Psychol Med 26:333–342PubMedGoogle Scholar
  25. Mari JJ, Streiner DL (1994) An overview of family interventions and relapse in schizophrenia: meta-analysis of research findings. Psychol Med 24:565–578PubMedCrossRefGoogle Scholar
  26. McCreadie RG, Phillips K (1988) The Nithsdale Schizophrenia Survey. VII. Does relatives’ high expressed emotion predict relapse? Br J Psychiatry 152:477–481PubMedCrossRefGoogle Scholar
  27. McDonell MG, Short RA, Berry CM, Dyck DG (2003) Burden in schizophrenia caregivers: impact of family psychoeducation and awareness of patient suicidality. Fam Process 42:91–103PubMedCrossRefGoogle Scholar
  28. McFarlane WR, McNary S, Dixon L, Hornby H, Cimett E (2001) Predictors of dissemination of family psychoeducation in community mental health centers in Maine and Illinois. Psychiatr Serv 52:935–942PubMedCrossRefGoogle Scholar
  29. McFarlane WR, Hornby H, Dixon L, McNary S (2002) Psychoeducational multifamily groups: research and implementation in the United States. In: McFarlane WR (eds) Multifamily group treatment for severe psychiatric disorders. Guilford, New York, pp 43–60Google Scholar
  30. McFarlane WR, Dixon L, Lukens E, Lucksted A (2003) Family psychoeducation and schizophrenia: a review of the literature. J Marital Fam Ther 29:223–245PubMedGoogle Scholar
  31. Möller-Leimkühler AM (2005) Burden of relatives and predictors of burden. Baseline results from the Munich 5-year-follow-up study on relatives of first hospitalized patients with schizophrenia or depression. Eur Arch Psychiatry Clin Neurosci 255:223–231PubMedCrossRefGoogle Scholar
  32. Montero I, Gomez-Beneyto M, Ruiz I, Puche E, Adam A (1992) The influence of family expressed emotion on the course of schizophrenia in a sample of Spanish patients. A 2-year follow-up study. Br J Psychiatry 161:217–222PubMedGoogle Scholar
  33. Pharoah FM, Rathbone J, Mari JJ, Streiner D (2003) Family intervention for schizophrenia. The Cochrane Database of Systematic Reviews, 3, Art. No.: CD000088. DOI: 10.1002/14651858.CD000088Google Scholar
  34. Pilling S, Bebbington P, Kuipers E, Garety P, Geddes J, Orbach G, Morgan C (2002) Psychological treatments in schizophrenia: I. Meta-analysis of family intervention and cognitive behaviour therapy. Psychol Med 32:763–782PubMedCrossRefGoogle Scholar
  35. Pitschel-Walz G, Leucht S, Bauml J, Kissling W, Engel RR (2001) The effect of family interventions on relapse and rehospitalization in schizophrenia-a meta-analysis. Schizophr Bull 27:73–92PubMedGoogle Scholar
  36. Pitschel-Walz G, Bauml J, Bender W, Engel RR, Wagner M, Kissling W (2006) Psychoeducation and compliance in the treatment of schizophrenia: results of the Munich Psychosis Information Project Study. J Clin Psychiatry 67:443–452PubMedCrossRefGoogle Scholar
  37. Ram Ms, Xiang Mz, Chan Cl, Leff J, Simpson P, Huang Ms, Shan Yh, Li S (2003) Effectiveness of psychoeducational intervention for rural Chinese families experiencing schizophrenia-a randomised controlled trial. Soc Psychiatry Psychiatr Epidemiol 38:69–75CrossRefGoogle Scholar
  38. Ruggeri M, Lasalvia A, Tansella M, Bonetto C, Abate M, Thornicroft G, Allevi L, Ognibene P (2004) Heterogeneity of outcomes in schizophrenia. 3-year follow-up of treated prevalent cases. Br J Psychiatry 184:48–57PubMedCrossRefGoogle Scholar
  39. Rutter M, Brown GW (1966) The reliability and validity of measures of family life and relationships in families containing a psychiatric patient. Soc Psychiatry 1:38–53CrossRefGoogle Scholar
  40. Scazufca M, Kuipers E (1998) Stability of expressed emotion in relatives of those with schizophrenia and its relationship with burden of care and perception of patients’ social functioning. Psychol Med 28:453–61PubMedCrossRefGoogle Scholar
  41. Stata Corp (2001) Stata Statistical Software, Release 7.0. Stata Corp., College Station, TXGoogle Scholar
  42. Stengard E (2003) Educational intervention for the relatives of schizophrenia patients in Finland. Nord J Psychiatry 57:271–277PubMedCrossRefGoogle Scholar
  43. Telles C, Karno M, Mintz J, Paz G, Arias M, Tucker D, Lopez S (1995) Immigrant families coping with schizophrenia. Behavioral family intervention v. case management with a low-income Spanish-speaking population. Br J Psychiatry 167:473–479PubMedGoogle Scholar
  44. Thornicroft G, Tansella M (2004) Components of a modern mental health service: a pragmatic balance of community and hospital care. Overview of systematic evidence. Br J Psychiatry 185:283–290PubMedCrossRefGoogle Scholar
  45. Tomaras V, Mavreas V, Economou M, Ioannovich E, Karydi V, Stefanis C (2000) The effect of family intervention on chronic schizophrenics under individual psychosocial treatment: a 3-year study. Soc Psychiatry Psychiatr Epidemiol 35:487–493PubMedCrossRefGoogle Scholar
  46. Üçok A, Polat A, Çakır S, Genç A (2006) One year outcome in first episode schizophrenia. Eur Arch Psychiatry Clin Neurosci 256:37–43PubMedCrossRefGoogle Scholar
  47. Vaughn C, Leff J (1976) The measurement of expressed emotion in the families of psychiatric patients. Br J Soc Clin Psychol 15:157–165PubMedGoogle Scholar
  48. Vaughn CE, Snyder KS, Jones S, Freeman WB, Falloon IR (1984) Family factors in schizophrenic relapse. Replication in California of British research on expressed emotion. Arch Gen Psychiatry 41:1169–1177PubMedGoogle Scholar
  49. Wearden AJ, Tarrier N, Barrowclough C, Zastowny TR, Rahill AA (2000) A review of expressed emotion research in health care. Clin Psychol Rev 20:633–666PubMedCrossRefGoogle Scholar
  50. World Schizophrenia Fellowship (1998) Families as partners in care: a document developed to launch a strategy for the implementation of programs of family education, training, and support. World Schizophrenia Fellowship, TorontoGoogle Scholar
  51. Xiong W, Phillips MR, Hu X, Wang R, Dai Q, Kleinman J, Kleinman A (1994) Family-based intervention for schizophrenic patients in China. A randomised controlled trial. Br J Psychiatry 165:239–247PubMedCrossRefGoogle Scholar

Copyright information

© Steinkopff Verlag Darmstadt 2006

Authors and Affiliations

  • Giuseppe Carrà
    • 1
    • 4
  • Cristina Montomoli
    • 2
  • Massimo Clerici
    • 3
    • 4
  • Carlo Lorenzo Cazzullo
    • 4
  1. 1.Department of Mental Health SciencesRoyal Free and University College Medical SchoolLondonUK
  2. 2.Department of Health Sciences, Section of Medical StatisticsUniversity of PaviaPaviaItaly
  3. 3.Department of PsychiatrySan Paolo’s Hospital Medical School, University of MilanMilanItaly
  4. 4.Association for Research on Schizophrenia (ARS)MilanItaly

Personalised recommendations