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Aims: Family psychoeducational programs have been shown to be effective in terms of knowledge acquirement and relapse prevention, but few studies have looked at whether one mode of educational method is more effective than another. The aim of the present study was to compare several modes of educational approaches and to elucidate which mode of education is more effective.
Methods: A total of 110 relatives of 95 patients with schizophrenia received three types of family psychoeducational programs between January 1995 and September 2003: a small group with two sessions (P1), a large group with nine sessions (P2), and a large group with five sessions (P3). In addition to the demographic data, acquired knowledge was measured using the modified Knowledge About Schizophrenia Interview (KASI), family expressed emotion (EE), and relapse episodes.
Results: Overall there were significant increases in many KASI subcategory scores after the three programs, in mothers in particular. The change in KASI scores indicated that the low EE group was able to be highly educated and that the relatives of non-relapsers were more effectively educated. As for the mode of the family psychoeducational program, the P1 and P2 groups surpassed the P3 in terms of knowledge acquired.
Conclusions: Effects of family psychoeducation may depend not on the number of members or sessions but on the time spent on the program per member.
THE PSYCHOEDUCATIONAL APPROACH specifically targeting the relatives of schizophrenia patients originates from a family expressed emotion (EE) study in the 1970s.1 When the families in that EE study were divided into two groups, families with high EE and those with low EE, it was found that discharged patients returning to a high EE family had a 3–4-fold higher risk of relapse than patients who returned to a low EE family.1 Based on this family diagnosis, psychoeducation for family members began in the 1980s, and its effectiveness in terms of relapse prevention has been widely confirmed.2–4 Consequently, some EE studies were performed in Japan, and the relationship of EE to schizophrenia relapse5,6 social function,7 and symptoms of depression8 became apparent. In addition, interventions through family psychoeducation were performed, and its effectiveness in preventing relapse was verified.9
With respect to the mode of intervention for families, there are common basic components of psychoeducation: education about the illness and its course, training in coping and problem-solving skills, improved communication, and stress reduction.10 Specifically, psychoeducation plays an important role, providing family members with psychological and social support by offering information on the causes and symptoms as well as methods to deal with the patient in a way that is easily understood, while taking into account the mental state of the family.11
Many studies assessing the effectiveness of family intervention are available; for example, family work conducted by Leff et al. was successful in curtailing the rate of schizophrenia relapse. That family work consisted of psychiatric staff making home visits to families living with a patient.12 Another example of family intervention is behavioral family therapy including communication skills and problem-solving techniques using role playing.13 It was not only helpful in decreasing the relapse rate, but also contributed to reduce the maintenance drug use. The psychoeducation program, which consisted of lectures attended by 20–40 adult family members of schizophrenia patients in the community, also produced positive results such as a reduced relapse rate and hospitalization period, improved psychiatric symptoms, and the recovery of certain social functions.14
We tested three patterns of family psychoeducational programs and have reported on a small part of the findings.15 This paper comprehensively presents the findings based on data collected through our family psychoeducational programs. The purpose of the present study was to determine which mode of education was more effective and to investigate the influence of other variables such as characteristics of families, EE, and relapse on the acquirement of knowledge.
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The present results show that family psychoeducational programs had substantial effects on relatives. First, relatives were able to acquire knowledge related to schizophrenia, particularly concerning the diagnosis, etiology, course/prognosis, and treatment. The present results are consistent with previous reports. Using the same tool, Barrowclough et al. demonstrated acquired knowledge in the areas of diagnosis, etiology, symptomatology, course/prognosis and management.19 Nishio et al. also reported an education effect in the areas of symptomatology and prognosis.20 It could be said that psychoeducation is useful to help relatives to understand the illness as a whole.
The present finding that low-EE relatives acquired more knowledge than those with high EE seems to be inconsistent with the Berkowitz et al. study.21 Contrary to the UK, relatives in Japan may receive little information from professionals and the level of knowledge at baseline was almost the same between high- and low-EE relatives. In addition to this, emotional reactions during the program may interfere with knowledge acquirement in high-EE relatives. Care for relatives, particularly those showing emotional reactions, may be necessary during the sessions.
The extent of acquired knowledge of relatives of non-relapsers was superior to that of relatives of relapsers. These findings agree with the previous reports such as that by Berkowitz et al. that family psychoeducation increased knowledge and brought about changes in family attitudes, leading to a decrease in the relapse rate.18,21 Ishibashi et al. produced similar results using the same instrument as ours.22 As noted here, there were no differences in relapse rate between the three programs, but significant differences in extent of acquired knowledge were found between P1 and P2/P3. Although we cannot rule out the possibility of confounding factors such as usage of antipsychotic drugs, it is suggested that education has the power of relapse prevention in non-relapsers, independent of style of programs.
The present findings are unique in that they were consecutively obtained at the same institution. We assumed that with our own video/text and after several trials, that the most recent P3 program was most effective; but the results were contrary to expectations: the P3 program was the least effective. It may be that the program effects depend on hypothetical time allotted to each participant in each session. This is calculated by (i) dividing the number of session hours by participating members and (ii) multiplying it by the number of sessions. It is approximately 60–80 min in P1, 54–108 min in P2, and 30–60 min in P3. In family educational programs the participant time may affect the consequences, thereby suggesting directions for developing teaching styles of family education.23
There were some limitations of the present study. First, the sample may not have represented the relatives because we could not collect questionnaires from all the participants; second, the small number of relatives weakened the statistical power; third, relapse was not defined as worsening of symptoms or functions; fourth, a more powerful research design such as randomized controlled trial is needed to answer these questions. In addressing these limitations, we will be able to point the way towards a more precise type of family psychoeducational program.
In conclusion, the effects of family psychoeducation in terms of acquirement of knowledge depends on the time spent on the program per member, which suggests the way toward a more precise type of family psychoeducational program.