Family psychoeducation with caregivers of schizophrenia patients: Impact on perceived quality of life.

BACKGROUND: Schizophrenia is a devastating and chronic mental illness. Considering the nature of illness along with routine psychiatric care, various supportive therapies are recommended. Family psychoeducational approach has been developed to increase patients' as well as their caregivers' knowledge and insight into their illness. It is postulated that this increased knowledge and insight will enable people with schizophrenia and their caregivers to cope in a more effective way with the consequences of their illness, thereby improving prognosis. AIM: The aim of this study is to assess the efficacy of family psychoeducation intervention on the caregivers of schizophrenia patients with respect to their perceived quality of life.
MATERIALS AND METHODS: A total of 30 caregivers of male schizophrenia patients were selected through purposive sampling technique. Patients were divided into two groups, namely, experimental and control group. Family psychoeducation intervention was given on twice-monthly basis for 6 months to the experimental group caregivers. Baseline assessment was carried out with the help of WHO Quality of Life-BREF followed by intervention and then posttherapeutic assessment was done with same tool.
RESULTS: Most of the caregivers were above 40 years of age group, married, and male. Following family psychoeducation, significant improvement in overall quality of life scores was observed in experimental group caregivers compared to control group caregivers where no such intervention was provided.
CONCLUSION: Family psychoeducation is feasible and useful in our clinical population. Copyright:

Family psychoeducation is the globally applied supportive and informative service, which is specially designed to provide factual information about mental illness to the psychiatric patients and their caregivers. It is offered by mental health professionals in order to modify and enhance their existing knowledge about mental illness and to make them able to cope more effectively in realistic way with the consequences of devastating mental illness like schizophrenia. It uses educational techniques, methods, and approaches to aid in the process of recovery from the disabling effects of mental illness or as an adjunct to the treatment of the mentally ill person and/or their caregivers. It has established its efficacy and effectiveness as an evidenced-based practice in improving compliance, relapse prevention, and positive effect on symptoms of schizophrenia.[12345]

The family psychoeducation approach recognizes that schizophrenia is a devastating brain disorder that is partially remediable with latest psychotropic molecules and that families can have a significant role in the process of their relative's recovery and relapse prevention. Studies related to family psychoeducation have established very promising results following family psychoeducation intervention on such clinical groups, especially on the caregivers. More than 30 evidence-based researches in these areas have demonstrated reduced relapse rates, improved recovery of patients, and improved family well-being among participants following family psychoeducation. It includes empathic engagement, education, ongoing support, clinical resources during periods of crisis, social network enhancement, and increasing problem-solving and communication skills among its participants.[6]

The feasibility of the family psychoeducational approach to schizophrenia and related mental disorders has been derived in part from their grounding in basic research. High levels of expressed emotion (critical, hostile, or emotionally overinvolved attitudes among relatives) were found to be predictive of the 9-month to 1-year course of schizophrenia. This finding has been repeated cross-nationally and in many different patients' subsamples also.[7] The consistency of the expressed emotion-outcome relationship has led many researchers to predict that interventions targeting high expressed emotion attitudes, as well as the aversive family interaction patterns with which expressed emotion attitudes are correlated, should lead to corresponding improvements in the course of schizophrenia and other psychiatric disorders.[8]

Several controlled trials have supported the contention that family psychoeducation treatment is superior to comparison psychosocial interventions in bringing about reductions in expressed emotion. Family psychoeducation has proved its effectiveness in delaying relapse rate in the schizophrenia patients, improving drug compliance, increasing knowledge about schizophrenia in caregivers of these patients, and satisfactory improvement in desired behavioral changes.[6]

In an experimental study, patients' perceived psychopathology, caregivers' quality of life, and family burden were studied in pre- and post-intervention conditions, and significant improvement were observed in caregivers quality of life and family burden in experimental group caregivers.[910] However, application of family psychoeducation in routine settings where patients having these disorders are usually treated has been limited, reflecting attitudinal, knowledge, practical, and systemic implementation obstacles. Moreover, major researches in these areas that have been done with the Western population. Very few studies have been conducted in the Indian setup. Therefore, the present study was undertaken to explore the efficacy and feasibility of family psychoeducation approaches with Indian clinical population.

MATERIALS AND METHODS

Study design

This was an experimental study conducted with 30 caregivers of schizophrenia patients selected through purposive sampling method from Ranchi Institute of Neuro-Psychiatry and Allied Sciences Outpatient Department. General Health Questionnaire-12 was used as screening tool for caregivers. Caregivers scoring <3 points were included in the sample.[11]

Inclusion criteria for caregivers

Educated caregivers (able to read Hindi interview schedule and respond to it without any assistance) who have been caring the patients after the onset of illness

Key caregiver who is staying with the patient at the same household for the period at least at least 2 years and above

Consenting to participate in the study.

Exclusion criteria for caregivers

Caregivers should not have any psychiatric illness, substance addiction, major physical illness, and any disability.

Family psychoeducation

In the present study, family psychoeducation was imparted to the schizophrenia patients and their caregivers during 1½ months period on twice-monthly basis. Thus, a total of six sessions were done, and each lasted for 1 hour. The whole theme of family psychoeducation was centered on imparting factual information about symptoms and clinical manifestations of schizophrenia, its consequence, how to deal with a members suffering from this illness at home, especially in relation to high expressed emotion and chances of relapse, identifying early sign and symptoms of illness and importance of regular psychotropic medications of the patients, and lowering affected family distress. It was brief, semi-structured, homogeneous (all schizophrenia), mixed family-based psychoeducation sessions, imparted to the patients and their caregivers of schizophrenia patients to increase the awareness about schizophrenia among participants and find out its relation to the perceived quality of life in caregivers.

Procedure

Diagnoses of the patients were confirmed as per the International Classification of Disease-10 Diagnostic Criteria for Research.[12] Positive and Negative Syndrome scale was used to assess the severity of the psychiatric problems in the patients.[13] Only those caregivers were included in the study who perceived the mild-to-moderate level of severity in their patients. Further, these 30 caregivers were separated into experimental and control groups with 15 participants in each group. Experimental group caregivers were imparted family psychoeducation for 1½ months on weekly basis (six sessions), whereas control groups caregivers were not given such intervention. A preassessment score was obtained using the WHO Quality of Life-BREF scale from both the groups. Family psychoeducation imparted to experimental group caregivers included education about schizophrenia, its clinical manifestation, how to handle their patients at home, importance of regular psychotropic medications of the patients, lowering affected family distress, educating to caregivers about importance of balanced expressed emotion toward their patients in relation to reduced relapse rate, and better tolerability of psychotic symptoms. Following intervention, postassessment score was obtained from both groups using the WHO Quality of Life-BREF.[14]

Statistical analyses

The collected data were tabulated and analyzed using the SPSS version 16.0 (IBM, USA). For comparison of data, Independent sample t-test or Chi-square test as appropriate was used for comparison of group data. Statistical analyses were performed with a significance level of <0.05.

RESULTS

Characteristics of the sample

Both experimental and control groups were matched in relation to sociodemographic profile. To know the significant differences between these two groups, Chi-square test (Fisher's exact test) was done, which showed no significant difference with respect to different sociodemographic variables [Table 1]. Out of 15 caregivers in experimental group, majority of caregivers (n = 7; 46.67%) belonged to 51+ years, were male (n = 13; 86.67%), hailing from rural areas of Jharkhand (n = 13; 86.67%). Most of them were married (n = 12; 80%), educated up to under matric (n = 12; 80%) and were having marginal single source of income which was

Table 1

Distribution of patients in experimental and control groups by different sociodemographic characteristics

Variables	Groups (n=30)		χ2/df (df=28)	P (significant)
	Experimental group (n=15), n (%)	Control group (n=15), n (%)
Age group (years)
<30	5 (33.3)	6 (40.0)	0.68	0.71 (NS)
31-35	5 (33.3)	6 (40.0)
≥36	5 (33.3)	3 (20.0)
Religion
Hindu	9 (60.0)	11 (73.4)	1.81	0.40 (NS)
Muslim	5 (33.3)	2 (13.3)
Others	1 (6.7)	2 (13.3)
Domicile
Rural	13 (86.7)	15 (100.0)	0.4828+	NS
Urban	2 (13.3)	0 (0.0)
Distance of home from hospital (km)
<500	12 (80)	11 (73.33)	0.186	0.666 (NS)
>500	3 (20)	4 (26.67)
Marital status
Married	10 (66.67)	10 (66.67)	0.00	1.00 (NS)
Unmarried	5 (33.33)	5 (33.33)
Educational qualifications
Illiterate	5 (33.33)	3 (20.0)	0.90	0.638 (NS)
Under matric	6 (40.0)	6 (40.0)
Above matric	4 (26.67)	6 (40.0)
Employment status
Employed	7 (46.67)	4 (26.67)	1.29	0.256 (NS)
Unemployed	8 (53.33)	11 (73.33)
Income (Rs.)
<5000	13 (86.67)	14 (93.33)	0.370	0.543 (NS)
>5000	2 (13.33)	1 (6.67)
Type of family
Nuclear	6 (40.0)	9 (60.0)	1.20	0.272 (NS)
Joint	9 (60.0)	6 (40.0)

+Fisher’s exact test; NS: Not significant

Caregivers quality of life data scores

Table 2 shows mean (± standard deviation [SD]) score of pretotal quality of life in caregivers' of experimental group was 36.47 ± 5.82 at baseline, and in postintervention condition, it was 51.87 ± 6.67 indicating significant improvement in perceived quality of life in caregivers following interventions, but in control group caregivers, the mean (± SD) score of total quality of life at baseline was 32.73 ± 3.51, and in postcondition, it was almost similar, i.e., 32.27 ± 5.06. Higher the mean score obtained indicate enhanced or better quality of life and lower the mean score obtained signifies poorer perceived quality of life by the caregivers of both experimental and control groups. Statically, these two groups differ significantly (t-test = 8.28, df = 28, P < 0.001).

Table 2

Comparison of caregivers of experimental and control groups before and after family psychoeducation and their gain of total quality of life scores

Variables	Groups (n=30), mean±SD		t-test (df=28)	P (significant)
	Experimental group (n=15)	Control group (n=15)
Total quality of life
Pre	36.47±5.82	32.73±3.51	−2.12	0.04**
Post	51.87±6.67	32.27±5.06	−9.06	0.00***
Difference (pre−post)	−15.40±5.57	0.47±4.90	8.28	0.00***

**P<0.01, ***P<0.001. SD – Standard deviation

Clinically significant total perceived quality of life scores in caregivers of experimental group was found (paired t-test = −10.717, df = 28, P < 0.001), but in control group, caregivers no as such significant findings could emerged. The mean score of pretotal quality of life score in experimental group was 36.47 ± 5.82, whereas in postcondition, it was 51.87 ± 6.67, shows increased mean score following interventions which is proportionally attached to enhanced quality of life. In control group caregivers, the mean of pretotal quality of life score was 32.73 ± 3.51, and in postassessment condition, it stands 32.27 ± 5.06, signifies almost same perceived quality of life in caregivers [Table 3 and Figure 1].

Table 3

Comparison of pre- and post-intervention total quality of life scores in caregivers of experimental and control groups

Groups (n=30)	Time point	Mean±SD	t-test (df=28)	P
Experiment (n=15)	Pretest	36.47±5.82	−10.71	0.00***
	Posttest	51.87±6.67
Control (n=15)	Pretest	32.73±3.51	0.36	0.71 (NS)
	Posttest	32.27±5.06

***P<0.001. SD – Standard deviation; NS – Not significant

Figure 1

Comparison of pretest and posttest with total quality of life scores in caregivers of control and experimental groups

DISCUSSION

Experimental group caregivers were imparted family psychoeducation in six sessions for 1½ months (on weekly basis). A range of psychosocial issues such as high expressed emotions toward their patients, patients' unemployment, day-to-day care burden, social isolation, and most of all uncertainty toward their patients future like “what would happen to their patients after them” were some of the sensitive issues that were discussed in family psychoeducation sessions. Initially, caregivers were hesitant to disclose their problems, but after forming the rapport between therapist and the caregivers, they could release their tension and ventilated in detail about their problems which further acted like a catalyst for other members as some of them were still hesitant even if they were repeatedly encouraged to share their problems.

Following intervention in interactive sessions, patients of both the group were reassessed on the quality of life scale which revealed significant improvements in terms of perceived quality of life in experimental group caregivers as compared to control group caregivers where no such improvements could be noticed. This finding was in consonance with an earlier study that found significant improvement in perceived well-being self-rated symptoms and subjective quality of life in two-thirds of the caregivers of patients with schizophrenia.[10]

Since in the present study, family psychoeducation was imparted for very brief period of time, i.e., for 1½ months and following which postassessment was done. Hence, this might be one reason that caregivers could retain maximum information with them which subsequently helped them to modify their misconception and ideas about mental illness and release their tensions of care burden even if for shorter period of time, and thus resulted in the enhanced quality of life. Moreover, in group situation the caregivers of schizophrenia patients interacted with other caregivers who were facing similar or even worse problems. This made them realize the universality of the caregiving burden. During family psychoeducation sessions, members could learn new coping and problem-solving skills from other fellow caregivers of the group in an empathetic environment. This might be one important factor contributing to better quality of life in the interventional group. On the other hand, in control group caregivers where no such family psychoeducation intervention was imparted, no improvement in perceived quality of life of caregivers was observed.

Limitations

This study has certain limitations. The sample size was small, and the duration of intervention was limited to 6 weeks. Many confounding variables of the caregivers' environments were also not controlled in the present study. In view of the above, the findings of the present study should be generalized with caution.

CONCLUSION

Schizophrenia affects not only the patients' life but also equally their caregivers. Hence, there is an urgent need to extend social support to such vulnerable group who are always at high risk to develop emotional problems. This study establishes the feasibility and effectiveness of family psychoeducation with caregivers of schizophrenia patients in our clinical population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.