Department of Psychiatry, Bispebjerg Hospital, Copenhagen, Denmark
Sct Hans Hospital, 4000 Roskilde, Denmark
Psychiatric Hospital Risskov, Denmark
Psychiatric Hospital Risskov, Denmark
Department of Psychiatry, Bispebjerg Hospital, Copenhagen, Denmark
Correspondence: Dr Pia Jeppesen, Bispebjerg Hospital, Department of Psychiatry, Bispebjerg Bakke 23, DK-2400, Copenhagen NV, Denmark. Tel: +45 353 12496; fax: +45 353 13558; e-mail: pj02{at}bbh.hosp.dk
Funding detailed in Acknowledgements.
*Paper presented attheThird International Early Psychosis Conference, Copenhagen, Denmark, September 2002.
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ABSTRACT |
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Aims To determine the effect of integrated treatment v. standard treatment on subjective burden of illness, expressed emotion (EE), knowledge of illness and satisfaction with treatment in key relatives of patients with a first episode of schizophrenia-spectrum disorder.
Method Patients with ICD10 schizophrenia-spectrum disorders (first episode) were randomly assigned to integrated treatment or to standard treatment. Integrated treatment consisted of assertive community treatment, psychoeducational multi-family groups and social skills training. Key relatives were assessed with the Social Behaviour Assessment Schedule (SBAS, burden of illness), the 5-min speech sample (EE), and a amultiple choice questionnaire at entry and after 1 year.
Results Relatives in integrated treatment felt less burdened and were significantly more satisfied with treatment than relatives in standard treatment. There were no significant effects of intervention groups on knowledge of illness and EE.
Conclusions The integrated treatment reduced family burden of illness and improved satisfaction with treatment.
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INTRODUCTION |
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The OPUS trial is a randomised trial of integrated treatment v. standard treatment in first-episode psychosis (Jorgensen et al, 2000). It has demonstrated several positive effects of integrated treatment compared with standard treatment: reduced levels of positive and negative symptoms, patients more satisfied with treatment, reduced number of in-patient days, and better continuity of treatment (Thorup et al, 2005).
The present paper reports the 1-year outcome of key relatives subjective burden in the trial. The hypotheses were that integrated treatment in comparison with standard treatment would: (a) reduce subjective burden of illness; (b) increase satisfaction with treatment; (c) improve knowledge of schizophrenia; and (d) increase the conversion of high EE to low EE in key relatives.
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METHOD |
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Inclusion and assessment of key relatives
The researcher asked permission to interview the closest relative or friend
of the patient. This key relative was contacted as soon as possible and asked
to give written consent to be interviewed. When two close relatives were
eligible, most often mother and father, both were invited to meet the
assessor, and the one with closest contact to the patient was interviewed. The
following hierarchy guided the choice of informant: (a) spouse; (b) parent;
(c) child; (d) sibling or other relative; (e) friend or others. We did not
demand a minimum level of contact between the relative and the patient.
Researchers carried out the interview at the office or in the
informants home at entry and after 1 year. The researcher was not
masked to treatment.
Integrated treatment
Three newly established multidisciplinary teams working with low case-load
(approximately ten patients for one team member) provided all the elements of
the 2-year integrated treatment programme. The integrated treatment can be
defined as a rich assertive community treatment model
(Stein & Test, 1980)
including protocols for medication, social skills training and
psychoeducational family treatment. The psychosocial elements were adapted to
meet the needs of patients during their first and second year of treated
illness. Use of antipsychotics followed the guidelines from the Danish
Psychiatric Society, which recommends a low-dose strategy for patients with
first-episode psychosis and the use of second-generation drugs as first
choice. Patients in need of social skills training were offered training at
home or in a group format after assessment with the Disability Assessment
Schedule (Holmes et al,
1982). The skills training focused on medication, coping with
symptoms, conversation, problem-solving and conflict-solving skills
(Liberman et al,
1986).
Patients in contact with at least one key person were encouraged to take
part in psychoeducational family treatment following McFarlanes manual
for multi-family groups (McFarlane et
al, 1995). The family treatment included: (a) three
individual family meetings to create an alliance with the family and review
the present crisis; (b) a survival skills workshop
(Anderson et al, 1986) with members of 46 families, given formal education about psychosis and
its management, aetiology and prognosis through lectures and discussions; (c)
18 months treatment involving 1 hours of therapy biweekly in a
multi-family group with two therapists and 46 families, including
patients. The multi-family groups focused on problem-solving and development
of skills to cope with the illness.
Standard treatment
Standard treatment consisted of the usual array of mental health services.
The case-load of the staff in the community mental health centre varied
between 1:20 and 1:30. Medication followed the same guidelines as integrated
treatment. In a small proportion of cases, key relatives met with the
consultant psychiatrist to be informed of the treatment or to give background
information. A few relatives in the standard treatment group participated in
workshops or groups for relatives.
Measures of outcome for key relatives
Burden of illness
Burden of illness was assessed with the Social Behaviour Assessment
Schedule (SBAS; Platt et al,
1980). SBAS is a semistructured interview that consists of three
dimensions: (a) disturbed behaviours; (b) change in social role performance;
and (c) adverse effects on others. For each item, the objective
change in the life of the relative is scored separately from the
distress or subjective burden caused by that particular
behaviour. Distress is used as a general description for any unpleasant
emotional response including worry, feelings of sorrow, anger or loss, etc.
The scale points are predefined and the ratings of distress are based on the
relatives verbal answers to the standardised questions. The distress
scale is: 0=no distress, 1=moderate distress, 2=severe distress. The
interviewers were trained in the interview technique and coding using
videotaped interviews, which were discussed in the group.
The SBAS has 35 items of relevance in all informantpatient relationships (Mors et al, 1992). These include 22 items on disturbed behaviours of patients, 5 items on social role performance and 8 items on adverse effects on the informant. For each dimension, the mean distress score was computed as the sum of scores divided by the number of applicable items.
Knowledge of schizophrenia
Knowledge of schizophrenia was measured by a multiple-choice questionnaire
translated and modified from McGill et al
(1983). We used 12 out of 14
questions covering the following aspects of the schizophrenia condition:
diagnosis, symptomatology, aetiology, medication, management and course of
illness. The relative was instructed to pick all the right answers. The total
number of correct answers out of 33 possible was the knowledge score.
Relatives satisfaction with treatment
Relatives satisfaction with treatment was measured with eight
questions adopted for relatives from the eight-item version of the Client
Satisfaction Questionnaire (Attkisson &
Zwick, 1982) and rated on a four-point Likert scale. Examples of
questions were: Do you feel that the professionals have been able to listen to
and understand your relative? Do you feel that the needs of your ill relative
were met? Are you generally satisfied with the treatment your ill relative has
received? The range of satisfaction sum scores was 832. Higher scores
represented a higher degree of satisfaction.
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Statistical analysis
Data handling and analysis were carried out using the Statistical Package
for the Social Sciences version 10.0 for Windows. All three mean distress
scores, the knowledge score and the satisfaction summed score were
approximately normally distributed. The difference between intervention groups
in mean distress score on each dimension of subjective burden (disturbed
behaviour, social role performance and adverse effects) and in knowledge score
at follow-up was analysed by analysis of covariance with treatment allocation
(intervention group) and the proper baseline entered as covariables.
Students t-test was used to analyse the difference between
intervention groups in relatives general satisfaction with treatment.
The proportion of relatives who converted from high EE to low EE was compared
between intervention groups with the MantelHaenszel method, adjusting
the change from high EE to low EE with change in the opposite direction from
low EE to high EE. Categorical response data were analysed with the Pearson
2 test. For continuous, non-normally distributed data we used
the MannWhitney test to analyse group differences. Attrition of
relatives at entry and at 1-year follow-up was analysed by logistic regression
analyses. All tests were two-tailed at the 5% level of significance.
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RESULTS |
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In a logistic regression analysis of participation v. non-participation of a key relative at entry, all characteristics of patients (see Table 1), intervention group and centre were entered as explanatory variables. Participation of a relative was significantly positively associated with the following characteristics of the patient: allocation to integrated treatment, >11 years of schooling, living in parents home, dual diagnosis with a harm or a dependence syndrome, and higher level of Global Assessment of Functioning (GAF) symptoms (best month in prior year), lower age, and Danish citizenship.
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Characteristics of the patients and key relatives by intervention group at entry
A total of 256 (79%) out of 325 included key relatives were females. A
total of 236 (73%) out of 325 relatives were parents, the remainder were
spouses (12%), siblings (9%), friends (5%), grandparents (2%) and children
(0.6%). The mean age of the key relatives was 47 years. The median duration of
illness, in the opinion of the key relative, was 2 years. On average, key
relatives had been in face-to-face contact with their relative 18 days in the
previous month. Although significantly more key relatives participated in the
integrated treatment group compared with the standard treatment group, there
were only three statistically significant differences between intervention
groups in characteristics of patients and key relatives at entry (see
Table 2). First, the mean level
of distress due to the patients behavioural disturbance was lower in
the integrated treatment group compared with the standard treatment group at
entry. Second, more patients in the standard treatment group compared with the
integrated treatment group had never married. Third, there was a statistically
significant difference in GAF functioning of the patient in the best month in
the prior year; the integrated treatment group scoring worse, mean (s.d.)=55.4
(16.2) v. 59.0 (15.7), P=0.04.
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Attrition during follow-up
Drop-out from re-interview at 1-year follow-up was investigated by a
logistic regression analysis. All characteristics of the included patients and
relatives, intervention group and centre were entered as explanatory
variables. Participation of a key relative at 1-year follow-up was
significantly positively associated with the following characteristics of the
patient and relative: allocation to integrated treatment, patient having
>11 years of schooling, Danish citizenship, and key relative being a
parent.
Outcome of key relative
Burden of illness
There was a significant beneficial effect of integrated v.
standard treatment on distress related to deficits in social role performance:
regression coefficient ß=0.17 (95% CI 0.32 to 0.02),
P=0.031, and a significant beneficial effect of integrated
v. standard treatment on distress related to adverse effects of
illness, ß=0.19 (95% CI 0.37 to 0.02),
P=0.047. There was no difference between intervention groups in
reduction of distress due to the patients disturbed behaviour,
ß=0.04 (95% CI 0.21 to 0.12); both groups improved
significantly (see Figure
2).
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Expressed emotion
The proportion of key relatives changing from high EE to low EE was 63.2%
in the integrated treatment group compared with 59.1% in the standard
treatment group. The proportion of key relatives changing from low EE to high
EE was 18.7% in the integrated treatment group compared with 12.5% in the
standard treatment group. The net reduction in EE was the same in both
intervention groups, see Table
3 (the net reduction in EE was compared with the
MantelHaenszel method (OR=0.84; 95% CI 0.401.76;
P=0.79)). There were no differences between intervention groups in
the proportion of relatives being emotionally overinvolved, critical, or both
at follow-up.
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Knowledge of schizophrenia
There was no effect of integrated v. standard treatment on
improvement in knowledge score, ß=0.9 (95% CI 0.5 to 2.3),
P=0.2. On average, the integrated treatment group had gained three
and the standard treatment group had gained two more correct answers at 1-year
follow-up.
General satisfaction with treatment
The mean satisfaction summed score was significantly higher in the
integrated treatment group compared with the standard treatment group at
follow-up. The mean difference was 3.4 (95% CI 2.14.7),
P<50.001. The difference can be illustrated as follows: relatives
in the integrated treatment group felt very satisfied, whereas relatives in
the standard treatment group felt only somewhat satisfied on almost half of
the questions.
Programme fidelity
Despite the effort to engage at least one family member in the treatment,
only 127 (68.6%) out of 185 key relatives allocated to the integrated
treatment group received one or more sessions of family therapy within the
first year. A total of 94 (50.8%) began multi-family group therapy, and 79
(42.7%) had six or more sessions of multi-family group sessions. In contrast,
only 27 (19.3%) out of 140 key relatives allocated to standard treatment
received one or more family meetings within the first year. Only five (3.6%)
had six or more family sessions including meetings in a relatives group
or self-help group.
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DISCUSSION |
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Despite skewed attrition of relatives from baseline interview, there were only three statistically significant differences between intervention groups at entry. Only one of these might have clinical significance, i.e. relatives in the integrated group felt less burdened by the patients behavioural disturbance at entry. This could be an effect of the first single-family sessions with integrated treatment relatives beginning before the point of assessment. Characteristics of patients by intervention group at entry showed several tendencies towards higher levels of symptoms and disability in the integrated treatment group compared with the standard treatment group. Thus, an eventual selection bias was more likely to work against the integrated treatment group. The study may be biased due to skewed attrition during follow-up, which is inborn when comparing treatments where one is designed to increase adherence of the patient and the relative to treatment. Lack of masking is a serious limitation of the study. Although the investigators themselves may believe they were not influenced by knowledge of therapy, others wishing to interpret trial results have a right to be sceptical. Researchers at each centre were trained in how to score SBAS and EE together, and EE ratings were consensus ratings among researchers in the centre. However, the interrater reliabilities across the two centres were not assessed. None of the psychometric scales were validated in Denmark. High EE attitudes were likely to be underestimated due to: (a) use of FMSS instead of the CFI; (b) assessment of one key relative instead of the entire household. Thus, there is a risk of misclassification.
The trial tested the hypotheses that the integrated treatment in comparison with standard treatment would: (a) reduce subjective burden of illness; (b) increase satisfaction with treatment; (c) improve knowledge of schizophrenia; and (d) increase the conversion of high EE to low EE in key relatives.
Findings supported the first and the second hypotheses, but not the third and the fourth hypotheses.
Only half the key relatives in the integrated treatment group had more than six sessions of family treatment. Specific measures of the process of psychoeducational family treatment, i.e. expressed emotion and knowledge of illness, showed no effect of intervention group. Despite these negative findings, integrated treatment compared with standard treatment proved effective in reducing the key relatives distress on two out of three domains: distress related to deficits in social performance of the ill family member and distress related to adverse effects of illness. The very high overall satisfaction with treatment among integrated treatment relatives is noticeable in view of their limited former experience with psychiatric treatment.
In summary, results generalise to mothers and other close relatives of Danish young adults coping with a first-episode of schizophrenia-spectrum disorder. Characteristics of the ill family members, like dual diagnosis, 11 or more years of schooling, living with a key relative or high levels of face-to-face contact predicted better adherence to the protocol and thereby to the psychoeducational family treatment.
Most studies of family interventions in schizophrenia are subjected to attrition of the same size and character as in our study (Barrowclough et al, 1999). The attrition limits the generalisability of findings. On the other hand, it emphasises the problems of adherence to family treatment models, which are also seen in those with first-episode psychosis.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Attkisson, C. C. & Zwick, R. (1982) The client satisfaction questionnaire. Psychometric properties and correlations with service utilization and psychotherapy outcome. Evaluation and Program Planning, 5, 233 237.[CrossRef][Medline]
Barbato, A. & DAvanzo, B. (2000) Family interventions in schizophrenia and related disorders: a critical review of clinical trials. Acta Psychiatrica Scandinavica, 102, 81 97.[CrossRef][Medline]
Barrowclough, C., Tarrier, N., Lewis, S., et al (1999) Randomised controlled effectiveness trial of a needs-based psychosocial intervention service for carers of people with schizophrenia. British Journal of Psychiatry, 174, 505 511.[Abstract]
Brown, G.W., Birley, J. L. T. & Wing, J. K. (1972) Influence of family life on the course of schizophrenic disorders: a replication. British Journal of Psychiatry, 121, 241 258.[Medline]
Holmes, N., Shah, A. & Wing, L. (1982) The Disability Assessment Schedule: a brief screening device for use with the mentally retarded. Psychological Medicine, 12, 879 890.[Medline]
Jorgensen, P., Nordentoft, M., Abel, M. B., et al (2000) Early detection and assertive community treatment of young psychotics: the Opus Study Rationale and design of the trial. Social Psychiatry and Psychiatric Epidemiology, 35, 283 287.[CrossRef][Medline]
Liberman, R. P., Mueser, K. T. & Wallace, C. J. (1986) Social skills training for schizophrenic individuals at risk for relapse. American Journal of Psychiatry, 143, 523 526.[Abstract]
Magana, A. B., Goldstein, J. M., Karno, M., et al (1986) A brief method for assessing expressed emotion in relatives of psychiatric patients. Psychiatry Research, 17, 203 212.[CrossRef][Medline]
McFarlane,W. R., Lukens, E., Link, B., et al (1995) Multiple-family groups and psychoeducation in the treatment of schizophrenia. Archives of General Psychiatry, 52, 679 687.[Abstract]
McGill, C.W., Falloon, I. R., Boyd, J. L., et al (1983) Family educational intervention in the treatment of schizophrenia. Hospital and Community Psychiatry, 34, 934 938.[Medline]
Mors, O., Sorensen, L.V. & Therkildsen, M. L. (1992) Distress in the relatives of psychiatric patients admitted for the first time. Acta Psychiatrica Scandinavica, 85, 337 344.[Medline]
Petersen, L., Nordentoft, M., Jeppesen, P., et al
(2005) Improving 1-year outcome in first-episode psychosis.
OPUS trial. British Journal of Psychiatry,
187 (suppl. 48), s98
s103.
Pharoah, F. M., Mari, J. J. & Strainer, D. (2000) Family intervention for schizophrenia. Cochrane Collaboration Database of Systematic Reviews, CD000088 .
Pilling, S., Bebbington, P., Kuipers, E., et al (2002) Psychological treatments in schizophrenia: I. Meta-analysis of family intervention and cognitive behaviour therapy. Psychological Medicine, 32, 763 782.[CrossRef][Medline]
Platt, S.,Weyman, A., Hirsch S., et al (1980) The Social Behaviour Assessment Schedule (SBAS): rationale, contents, scoring and reliability of a new interview schedule. Social Psychiatry, 15, 43 55.[CrossRef]
Stein, L. I. & Test, M. A. (1980) Alternative to mental hospital treatment: I. Conceptual model, treatment program, and clinical evaluation. Archives of General Psychiatry, 37, 392 397.[Abstract]
Thorup, A., Petersen, L., Jeppesen, P., et al (2005) Integrated treatment ameliorates negative symptoms in first episode psychosis results from the Danish OPUS trial. Schizophrenia Research, in press.
Wearden, A. J., Tarrier, N., Barrowclough, C., et al (2000) A review of expressed emotion research in health care. Clinical Psychology Review, 20, 633 666.[CrossRef][Medline]
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