Efficacy of family psychoeducation on drug compliance, self-esteem and caregivers' burden among selected psychiatric inpatients from a tertiary care centre, North India.

Background: Lack of awareness has alarmingly raised the proportion of drug noncompliance among psychiatric patients, which are proven worrisome not only to the patients but also to their caregivers. An individually tailored family psychoeducation will address the issue by enhancing the knowledge among patients and their caregivers. Aim: The aim of this study is to assess the efficacy of family psychoeducation on drug compliance, self-esteem, and caregiver's burden among psychotic and mood disorder patients in a selected tertiary care center, Uttarakhand, India.
Methods: A quasi-experimental study was performed among 120 participants using total enumerative sampling in a general hospital psychiatric ward. Data were collected from patients and caregivers using the Medication Adherence Rating Scale, Rosenberg Self-esteem Scale, and Zarit burden interview-22. The outcome measures were evaluated in the 2 and 4th weeks, and data were analyzed using the descriptive (frequency, percentage) and inferential statistics (Friedman analysis of variance, Wilcoxon signed-rank test) using the SPSS software version 23.0.
Results: The present study showed that almost 30% of patients were noncompliant with their drug regime (mean ± standard deviation, 4.23 ± 1.57), and a majority (63.33%) of them presented with a low level of self-esteem. Furthermore, 71.7% and 13.3% of caregivers experienced a moderate and severe burden. An increase in drug compliance (35%) and self-esteem (31%) and a decrease in caregivers' burden (13%) were observed after the administration of family psychoeducation (P = 0.00).
Conclusion: There is a great need to provide family psychoeducation on a routine basis in general hospitals. Patients with higher self-esteem will ultimately show improved social and occupational functionality resulting in satisfactory treatment compliance and decreased caregivers' burden. Copyright:

Mental disorders, especially schizophrenia, bipolar disorders, anxiety, and depression, display an increasing trend these days, with an estimated prevalence of 22.1% globally.[1] Psychotic disorders affect 20 million, and bipolar affective disorder impacts 45 million, while depression attacks around 264 million people worldwide.[2] In India, it is reported, 13.7%, i.e., closely around 150 million, presents with a lifetime prevalence of mental illnesses.[3] Furthermore, in the recent literature of the North Indian region, Uttarakhand suggests an overall prevalence of depression as 6%.[4]

With the latest advancements and flow of a major portion of resources in psychiatry, there remains a significant gap in the treatment of mental disorders as patients are still notwithstanding along the prescribed regime.[5] Compliance issues are usually considered the principal reason for the substantial worsening of mental disorders. Drug compliance refers to the extent to which medication intake is consistent with medical prescriptions.[678] Drug noncompliance implies the patient does not take the prescribed drugs or discontinues a drug before completing the regimen, changing the drug dosage and timetable, or following treatment instructions. The extent of noncompliance varies widely, ranging from 10% to 92%[91011] with partial or total noncompliance were as high as 60% and 40% among patients with schizophrenia and bipolar disorders, respectively, thereby leading to an increased risk of drug resistance, disease relapse, remission, and re-hospitalization by manifolds.[1112]

In addition to drug compliance, higher self-esteem and healthy coping mechanisms prove to be promising key constructs in favorable recovery and prevention from undue relapses. Self-esteem is a subjective feeling perceived by an individual about self.[13] Research reviews suggest that 17.3% of patients with major mental disorders experience extremely low levels of self-esteem with schizophrenic patients, accounting for magnitudes as high as 24.6%[14] Patients showing higher levels of self-esteem will ultimately show improved social and occupational functionality resulting in satisfactory treatment compliance, directly decreasing the burden of caregivers.[15]

It has been observed that people caring for sufferers also suffer from them, which often goes unnoticed. A recent study estimates that 40.9% and 59.1% of caregivers of the mentally ill account for severe and moderate levels of burden, respectively.[16] A higher burden of care was noted among 49% of caregivers of schizophrenic patients.[17] About 50%–80% of schizophrenic patients reside or are in regular contact with their caregivers, often relying on them for housing, financial, and emotional support.[18]

Despite the fact, family support plays a significant role in the early recovery of patients, Indian families confront a range of difficulties while caring for them, such as low or no awareness about mental illness, improper information, difficulty in availing services, and lack of facility and resources.[19] Despite numerous attempts, mental illnesses are mushrooming all over, due to which there arises an urgent need for global guidance on effective, culturally appropriate, and sustainable psychosocial interventions for mental disorders, especially in low- and middle-income countries.[20] A recent Indian study by Devi and Konnur revealed that family psychoeducation helped raise knowledge scores about medications and their adverse effects by 29.35% and relapse prevention by 27.6%.[21] A meta-analysis preferred psychoeducation involving family members as it was more effective in reducing symptoms and preventing relapse.[22]

Thus, it is the need of the hour to maximally direct our efforts in spreading awareness to psychiatric patients and their caregivers. It will help them get more information and make them competent in dealing with the disease, and hence, maximizing their potential in resuming with their premorbid personalities. Therefore, the present study evaluated the efficacy of family psychoeducation on drug compliance, self-esteem, and caregiver's burden among patients with psychotic and mood disorders in the selected tertiary care center, Uttarakhand.

METHODS

Study design

A quantitative quasi-experimental research approach, one group pre- and posttest design, was used in which the researcher observed the efficacy of intervention at two different points of time. Figure 1 depicts the methodology of the study.

Figure 1

CONSORT diagram for single-arm study

Setting

The research study was conducted at the inpatient department (Psychiatric Ward) of the All India Institute of Medical Sciences, Rishikesh, India, a tertiary care teaching hospital providing outpatient and inpatient psychiatric services. The data were collected from November 2019 to January 2020.

Participants

Patients diagnosed with psychotic and mood disorders according to the International Classification of Diseases 10 criteria (F20-29 and F30-39), who were admitted in the psychiatric ward were selected as the study sample. A total enumerative sampling technique was adopted to draw the samples to prevent intervention contamination.

Patients who were 19 years old or above and had at least one relapse were included, while those with active psychotic symptoms and mental retardation were excluded from the study. Caregivers who stayed with the patient for more than a year and did not have any diagnosed mental illness were included. Data were collected from the participants who could verbally respond to questions and comprehend session (s).

Sample size

The sample size was collected using the results of the pilot study by adopting the formula:

Where, n = Sample size; σ1 = Standard deviation (SD) 1; σ2 = SD 2; m1 = Mean 1; m2 = Mean 2; Z = Confidence interval 5%; z1-α/2= 1.96; z1-β = 1.28

Total sample size calculated for the study = 100 (50 patients + 50 caregivers)

Considering the 10% drop rate, sample size of 60 patients along with 60 respective caregivers was taken for the study.

Ethical considerations

Ethical permission was obtained from the Institutional Ethical Committee (Registration No.: ECR/736/Inst/UK/2015/RR-18). Anonymity and confidentiality of information were maintained and informed about their freedom of choice. Informed written consent was obtained from the participants before initiating the data collection process.

Questionnaires

Standardized tools were used to carry out the assessment and evaluation with permission from respective authors. Tool reliability was assessed using the internal consistency (Karl Pearson's correlation co-efficient) method. Internal and external validity was also established. Tools were translated in the local language (Hindi) and validated by field experts, followed by the one-to-one bilingual translation. A try out for translated tools was conducted to check for their feasibility in the selected setting.

Sociodemographic and clinical profile, a range of background data gathered to determine the representative nature of the sample. Information regarding age, gender, years of education, occupation, family income, religion, family type, and residence type was collected. The clinical parameters included age of onset of illness, the total duration of disease, and family history of psychiatric disorder.

Medication adherence rating scale, a 10-item self-report multidimensional scale, is used to assess individuals’ behavior or attitude toward their medication during the past week.[23] Total scores may range from 0 to 10, where a higher score suggests better medication adherence. In the present study, patients scoring <3 were considered nonadherent, 3–5 mildly adherent, 6–8 moderately adherent, and >8 fully adherent. Tool reliability for the current setting was 0.73.

Rosenberg Self-esteem Scale[24] is a 10-item uni-dimensional scale that is used to assess the level of self-worth and self-acceptance by measuring both positive and negative feelings about self, developed by Rosenberg M, 1965. It is a 4-point Likert scale format ranging from strongly agree to strongly disagree. The minimum total score is 0, and the maximum is 30, with higher scores representing higher self-esteem. A score between 15 and 25 is considered average. A score of <15 may indicate problematic low self-esteem. Tool reliability established for the current setting was 0.75.

Zarit burden interview-22[25] is a 22-item self-administered scale used to assess the level of burden experienced subjectively by principal caregivers of chronically ill patients, developed by Zarit SH et al. in 1980. It is a 5-point Likert scale with scores ranging from 0 to 88 were 0–20 represents no or minimal burden, 21–40 mild to a moderate burden, 41–60 moderate to a severe burden, and 61–88 severe burden. Tool reliability computed for the setting was 0.80.

The tool administrator clarified the statement of the tool by re-reading the question verbatim without changing the wordings to facilitate understanding by participants. After obtaining ethical clearance, a pilot study was conducted on 20 participants (10 patients and 10 caregivers). Participants involved in the pilot study were excluded from the main study.

Family psychoeducation intervention

Followed by the baseline assessment, along with routine care, family psychoeducation was administered. Over the course of 2 weeks, the participants received 60 min of five sessions. The researcher designed a bilingual family psychoeducational intervention module using Macmaster's approach to family assessment and treatment[26] and a psychoeducation manual for bipolar disorder,[10] which was validated by the experts of psychiatry, clinical psychology, psychiatric nursing, and psychiatric social work. The primary investigator conducted the sessions, a postgraduate in psychiatric nursing and her supervisors (psychiatric nursing faculty and psychiatrist). Each family psychoeducation session aimed at improving five core areas: illness awareness, treatment adherence, problem-solving skills, communication/interpersonal skills, and caring for the caregivers. The fluid power equipment was delivered in a group format where 6–8 patients and their caregivers attended in a given time.

Each session began with an overview of the learning objectives and each participant's role. Before commencing the discussion, the participants’ perspectives on the topic were asked. The participants actively participated in the sessions by adopting interactive teaching tactics such as videos, case scenarios, role play, and PowerPoint presentations. As a technique of relaxation, all of the sessions included deep breathing exercises and various recreational activities.

A posttest and follow-up test was given after all sessions were completed, and the data were collected by people other than the lead investigator to verify that the results were not biased. The description of the session is mentioned in Table 1.

Table 1

Contents of Family Psychoeducation Intervention Program

The theme of each session	Objectives	Contents
Session-1	To establish rapport with the patients and caregivers	Group formulation and rapport establishment.
Introduction and briefing of illness		Ice-breaking activity.
	To educate participants about the nature of illness and early warning signs	Brief discussion on nature of illness - Mood and psychotic disorders
	To discuss the benefits of family psychoeducation	Minisession on family psychoeducation intervention -benefits, goals and course
		Deep breathing exercises.
Session 2	To discuss the importance of treatment adherence	Discuss patient updates; review from previous sessions
Treatment adherence		Creative healing activity
	To brief about various side effects of psychotropic drugs and early recognition of warning signs	Miniteaching on role of psychotropic medication
		Deep breathing exercises
		Group education on treatment adherence and side effects
		Recreational activity - star activity
Session3	To explain problem-solving techniques to the participants	Review patient updates; feedback of the previous session
Problem solving		Deep breathing exercises
	To enable participants to incorporate problem-solving skills in their day-to-day lives	Minilecture on problem-solving technique
		Group activity - case scenario illustrations on problem-solving
		Fun activity
		Solve the knot - problem-solving
		Picture coloring activity
Session4	To discuss common problems while communicating with patients	A brief review of problem-solving techniques
Communication skill training		Deep breathing exercises
	To enable the caregivers to practice therapeutic communication skills	Fun activity - misunderstanding
		Minilecture - communication training skills
		Fit together exercises
		Recreational activity - join the dots
Session 5	To empower caregivers to take care of themselves while caring for the ill ones	Review previous session details
Caring for caregivers		Case scenario discussion - problems faced by caregivers
		Pencil exercise
		A mini-lecture on self-care for caregivers
		Deep breathing exercises
		Feedback and suggestions from participants

Data analysis

Data were analyzed using Statistical Package for Social Sciences (SPSS 23.0) developed by International Businesses Machines Corporation (IBM), New York, USA by descriptive and inferential statistics. Sociodemographic, clinical profile, and level of drug compliance, self-esteem, and caregiver's burden were assessed using frequency, percentage, mean, SD. The overall intervention effect was assessed using the Friedman analysis of variance and Wilcoxon signed-rank test.

RESULTS

Data were collected from 120 participants (60 patients and 60 caregivers), and Tables 2 and 3 show the sociodemographic and treatment profiles of the participants.

Table 2

Sociodemographic profile of participants (n=120)

Sociodemographic characteristics	Frequency, n (%)
	Patients (n=60)	Caregiver (n=60)
Age (years) (mean±SD)	33.97±13.35	43.02±11.87
Gender
Male	35 (58.3)	32 (53.3)
Female	25 (41.7)	28 (46.7)
Marital status
Unmarried	26 (43.3)	7 (11.7)
Married	27 (45)	47 (78.3)
Othersδ	7 (11.7)	6 (10)
Qualification
≤12th standard	38 (63.3)	34 (56.7)
Undergraduate	16 (26.7)	23 (38.3)
Postgraduate and/or higher	6 (10)	3 (5)
Occupation
Unemployed	27 (45)	4 (6.7)
Student	12 (20)	0
Government employee	2 (3.3)	5 (8.3)
Private employee	8 (13.3)	22 (36.7)
Business	0	3 (5)
Homemaker	11 (18.3)	26 (43.3)
Habitat
Rural habitat	25 (41.7)
Urban habitat	35 (58.3)
Religion
Hindu	48 (80)
Muslim	12 (20)
Type of family
Nuclear	38 (63.3)
Joint	22 (36.7)
Total number of family members
<5	10 (16.7)
5-10	39 (65)
>10	11 (18.3)
Socioeconomic status
Upper	2 (3.3)
Upper middle	19 (31.7)
Lower middle	23 (38.3)
Upper lower	11 (18.3)
Lower	5 (8.3)

δOthers: Separated and widowed. SD – Standard deviation

Table 3

Treatment and Caregivers’ Profile (N=120) and text of title can be at centre

Treatment profile of patients		Caregivers’ profile
Variables	Frequency (n=60), n (%)	Variables	Frequency (n’=60), n (%)
Diagnosis		Relationship with patient
Mood disorders	16 (26.7)	Parent	27 (45)
Psychotic disorders	44 (73.3)	Spouse	11 (18.3)
		Sibling	12 (20)
		Others¥	10 (16.7)
Previous hospitalization		Duration of caregiving (years)
Present	37 (61.7)	<5	26 (43.3)
Absent	23 (38.3)	>5	34 (56.6)
Length of present hospital stay (days)		Attitude towards patient
Mean±SD	17.95±9.32	Highly interested	7 (11.7)
<7	2 (3.3)	Interested	48 (80)
7-21	41 (68.3)	Least interested	5 (8.3)
22-30	12 (20)
>30	5 (8.3)
Total duration of illness (years)		Availability of social support
<2	20 (33.3)	Full	7 (11.7)
2-5	19 (31.7)	Partial	38 (63.3)
>5	21 (35)	None available	15 (25)
Monthly psychiatric medication expenses (INR)		General health status
<500	7 (11.7)	Good	7 (11.7)
500-1000	36 (60)	Fairly satisfactory	13 (21.7)
>1000	17 (28.3)	Frequently ill	8 (13.3)
Availability of mental health facility nearby		Not checked	32 (53.3)
Present	28 (46.7)
Absent	32 (53.3)

Others¥: Cousins, paternal uncle and aunt, mother-in-law and maternal aunt. SD – Standard deviation; INR – Indian Rupees

Prevalence of drug compliance and self-esteem among patients with psychotic and mood disorders

Around 30% of the patients were entirely nonadherent to the prescribed regime, whereas 70% of them were mildly adherent with a total mean (SD) of 4.23 (1.57). Besides, Table 4 shows that a maximum number of patients had a low level of self-esteem (63.33%).

Table 4

Level of self-esteem among patients with mood and psychotic disorders (n’=60)

Level of self-esteem	Frequency, n (%)
Low (<15)	38 (63.33)
Average (15-25)	17 (28.33)
High (>25)	5 (8.34)

Prevalence of caregivers’ burden

A considerably high level of burden was noted among those caring for people with chronic illnesses, especially mental disorders [Figure 2].

Figure 2

Level of caregivers’ burden

Effectiveness of psychoeducation on drug compliance, self-esteem, and caregivers’ burden

Table 5 depicts the intervention effects on drug compliance, self-esteem, and caregivers’ burden by comparing the mean scores at different time points.

Table 5

Efficacy of Family Psychoeducation on Outcome Variables (N=120) and text of table title can be at centre

a. Level of drug compliance, self-esteem and caregivers’ burden at different intervalsa
Variable	Baseline (O1)		Posttest (O2)		Follow-up test (O3)		df	P
	Mean±SD	Mean rank	Mean±SD	Mean rank	Mean±SD	Mean rank
Drug compliance	4.23±1.57	1.27	6.35±1.82	2.71	5.73±1.65	2.18	8	0.00*
Self-esteem	13.67±4.65	4.02	16.02±3.84	5.05	17.93±3.91	5.78	8	0.00*
Caregiver’s burden	48.95±7.34	8.98	45.40±6.43	7.82	42.98±6.66	7.20	8	0.00*
b. Comparison between test scores of drug compliance, self-esteem, and caregivers’ burden at different intervalsb
Variable	Baseline - posttest (O1-O2)		Posttest - Follow-up test (O2-O3)		Baseline - Follow-up test (O1-O3)
	Z	P	Z	P	Z		P
Drug compliance	6.26	0.000*	2.97	0.003*	5.38		0.000*
Self-esteem	5.93	0.000*	5.75	0.000*	6.37		0.000*
Caregiver’s burden	6.77	0.000*	4.66	0.000*	6.67		0.000*

a. Baseline (O1) done before intervention; posttest (O2) done after 2 weeks of intervention; follow-up test (O3) done after 4 weeks of intervention; *P=Significant at P<0.05. Statistical test: Friedman ANOVA, b. Post hoc analysis using Bonferroni adjustment at 0.017; *P=Significant at P<0.05; Statistical test: Wilcoxon signed-ranks test. SD – Standard deviation

DISCUSSION

The present study suggests that, out of 60 patients, 30% were completely nonadherent to the medications prescribed, whereas 70% were partly adherent, and none of them lied in the category of fully adherent on the drug compliance rating scale (MARS). These findings are consistent with a cross-sectional study, which suggests an overall incidence of nonadherence due to drug-related factors as 32%.[27] Furthermore, a systematic review and meta-analysis revealed that 49% of patients with major psychiatric illnesses (including schizophrenia, major depressive disorders, and bipolar disorders) were nonadherent to their psychotropic medications.[28]

The possible reasons for medication nonadherence can include the patient factors (i.e., the fear of adverse effects, physical and psychiatric conditions, forgetfulness, external distractions, misunderstanding instructions, lack of insight, and lack of information about disorders), treatment factors (i.e., numerous medications, enduring symptoms, and partial or no efficacy), and socioeconomic factors (i.e., insufficient income, transportation, homelessness, and stigma of mental illness). Other barriers may include a lack of structured education to patients and their caregivers, which may help them acquire skills that improve treatment compliance.

Due to the chronicity of illness and poor drug compliance, the self-esteem needs of patients with psychotic and mood disorders often go unnoticed. A recent study advocates a prevalence of self-stigma as high as 54.44%.[14] The present study also yielded results in favor of previous studies reporting low self-esteem in 63.33%, average self-esteem in 28.33%, and high self-esteem in only 8.34% of patients.

The current study revealed that out of 60 caregivers, 15% had a severe burden, 71.7% had moderate-to-severe levels, and 13.3% presented with mild to moderate burden. These study findings were supported by Navidian et al.,[29] who reported 73.6% of moderate-to-severe levels of burden among caregivers. The latest study also suggested that a marginally high number (56%) of caregivers possessed moderate-to-severe burden.[30] However, Shamsaei reported that 27.1% had a severe burden, 41.8% had moderate-to-severe burden, and 23.5% had a mild-to-moderate burden.[31]

Family psychoeducation significantly improved drug compliance (P = 0.00) and self-esteem (P = 0.00) among patients and decreased burden (P = 0.00) among caregivers. These findings were consistent with other studies Ahmed et al. and Bahredar et al., who reported an increase in the score of drug compliance from 6.27 to 7.92 at the 6-month interval, while in the present study, mean scores increased from 4.23 to 6.35 at 2 weeks interval and 5.73 at 4 weeks interval postintervention.[3233] Similarly, researches from India reported improved self-esteem (P = 0.00) after group psychoeducation in bipolar patients.[343536]

The current study also revealed a marked reduction in caregivers’ burden (P = 0.00). Similarly, Navidian reported a significant decrease in the mean score of Zarit burden interview (P = 0.00).[29] Psychoeducational family intervention by Sampogna et al. decreased caregivers’ burden at the end of the intervention (0 = 0.02).[37] Similarly, other studies also proved that family intervention has long-term effects on patients and caregivers, thus improved family functioning.[3438]

Extended contact, focusing mainly on education of illness, treatment compliance, problem-solving, and communication skills, became the crucial elements in increasing drug compliance, self-esteem among patients, and reduced burden among caregivers.

Limitations

This study, however, had certain limitations as it was a single-centric study, limited to one group and used nonprobability sampling. Nevertheless, this study is a first of its kind in Uttarakhand, India, with limited mental health resources and services. The study also proved nurse-led family psychoeducation is feasible in a general hospital psychiatric setting, thus contributing to the socio-occupational functioning of persons with psychotic and mood disorders.

CONCLUSION

The study results proved that a brief, structured, family psychoeducation effectively reduces noncompliance and caregivers’ burden and increases self-esteem among psychiatric inpatients. This family education, in a way, reunited sufferers and carers and proved to be a vent to express their thoughts and feelings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.