Family Psychoeducation in Long-Term Treatment of Patients with Psychosis

October 23, 2018

Charles Sanky

Introduction
 Majority of patients we see on the unit experience psychosis, often secondary to
substance abuse, medical etiologies, schizophrenia-spectrum, bipolar disorder, or
other psychiatric diagnoses.
 Standard therapies include first- and second-generation antipsychotics, often
coupled with mood stabilizers.
 Problems: side effects, trial-and-error efficacy, compliance.
 Compliance is more complicated than patient choice. Biopsychosocial model:
o Biological factors (genetic predispositions, disease progression, treatment
side effects)
o Psychological factors (depression, stress, identity, guilt)
o Social factors (access to care, career, purpose, financial stability, drug use,
family and social support)
 Need for long-term therapies to address all of these factors.
o Biological and psychological factors are usual targets in inpatient
psychiatry.
 Injectable medications in improving compliance.
 Follow-up with psychiatrists to manage disease course, potential
side effects and new symptoms.
o Importance of social factor interventions to minimize future
hospitalization and progression of biological/psychological deterioration.
 Stable housing, financial assistance
 Case managers
 Novel medication management systems (DOT, eDOT)
 FAMILY

Role of Families
 Patients with psychosis do not seek help on their own.1
 Family and social support as #1 predictor of health outcomes (diabetes2,
hypertension3, all medication adherence4 - purchasing and administration).
 General medical adherence is 1.74 times higher in patients from cohesive families
and 1.53 times lower in patients from families in conflict5
1
O’Callaghan, E., Turner, N., Renwick, L. et al. Soc Psychiat Epidemiol (2010) 45: 381.
https://doi.org/10.1007/s00127-009-0081-x
2
Miller TA, Dimatteo MR. Importance of family/social support and impact on adherence to diabetic therapy. Diabetes
Metab Syndr Obes. 2013;6:421-6. Published 2013 Nov 6. doi:10.2147/DMSO.S36368
3
“Social support and management of hypertension in South-west Nigeria” Cardiovascular journal of Africa vol. 26,1
(2015): 29-33.
4
Johnson, V., Jacobson, K., Gazmararian, J. and Blake, S. (2010). Does social support help limited-literacy patients with
medication adherence?. Patient Education and Counseling, 79(1), pp.14-24.
5
DiMatteo, M. R. (2004). Social Support and Patient Adherence to Medical Treatment: A Meta-Analysis. Health
Psychology, 23(2), 207-218.
  Problems:
o Low SES, people of color, poor health literacy.6
o Pre-existing lack of social support, or consequent of disease.
o Caregiver burnout: elevated levels of depression, anxiety, and stress78
o Lack of evidence-based medicine regarding specific interventions in the
social sphere.
 Integrated psychosocial treatment program for schizophrenia and substance
use disorders.
o RCT comparing routine care to program integrated with motivational
interviewing, CBT, and family intervention.9
o Improved patient function reduced positive symptoms, symptom
exacerbation, and abstinence from drugs or alcohol for 1 year.
 Current interventions for schizophrenia:
o Culturally informed family therapy10
 Outperformed standard family psychoeducation, fostered
family cohesion, reduced patient schizophrenia symptoms,
reduced family distress and affective symptoms.
o Multiple Family Groups11
 Over 12 months, participants in the multiple-family group
(stratified) experienced significantly reduced negative symptoms
compared with those receiving standard care.
 Taking atypical antipsychotic medication or having a diagnosis of
substance abuse was not associated with the severity of negative
symptoms.
 Future directions:
 Other diseases (borderline personality disorder12)

6
López, S., Gamez, D., Mejia, Y., Calderon, V., Lopez, D., Ullman, J. and Kopelowicz, A. (2018). Psychosis Literacy
Among Latinos With First-Episode Psychosis and Their Caregivers. Psychiatric Services, p.appi.ps.2017004.
7
Cuijpers, P. and Stam, H. (2000). Burnout Among Relatives of Psychiatric Patients Attending Psychoeducational
Support Groups. Psychiatric Services, 51(3), pp.375-379.
8
Zanetti, A., Souza, T., Tressoldi, L., de Azevedo-Marques, J., Corrêa-Oliveira, G., Silva, A., Martin, I., Vedana, K.,
Cardoso, L., Galera, S. and Gherardi-Donato, E. (2018). Expressed emotion and family burden in relatives of patients in
first-episode psychosis. Archives of Psychiatric Nursing, 32(3), pp.390-395.
9
Barrowclough, C., Haddock, G., Tarrier, N., Lewis, S., Moring, J., O’Brien, R., Schofield, N. and McGovern, J. (2001).
Randomized Controlled Trial of Motivational Interviewing, Cognitive Behavior Therapy, and Family Intervention for
Patients With Comorbid Schizophrenia and Substance Use Disorders. American Journal of Psychiatry, 158(10), pp.1706-
1713.
10
Brown, C. A., & Weisman de Mamani, A. (2018). The mediating effect of family cohesion in reducing patient symptoms
and family distress in a culturally informed family therapy for schizophrenia: A parallel-process latent-growth
model. Journal of Consulting and Clinical Psychology, 86(1), 1-14.
11
Dyck, D., Short, R., Hendryx, M., Norell, D., Myers, M., Patterson, T., McDonell, M., Voss, W. and McFarlane, W.
(2000). Management of Negative Symptoms Among Patients With Schizophrenia Attending Multiple-Family
Groups. Psychiatric Services, 51(4), pp.513-519.
12
Betts J, Pearce J, McKechnie B, et al. A psychoeducational group intervention for family and friends of youth with
borderline personality disorder features: protocol for a randomised controlled trial. Borderline Personal Disord Emot
Dysregul. 2018;5:13. Published 2018 Jul 25. doi:10.1186/s40479-018-0090-z
  Patient group sessions coupled with family group sessions,
information sheets. Low referral rate of clinicians (10%),
influenced by hospital resources, stigma, logistical issues,
reimbursement.13
 Building social support

13
Mirsepassi, Z., Tabatabaee, M., Sharifi, V. and Mottaghipour, Y. (2018). Patient and family psychoeducation: Service
development and implementation in a center in Iran. International Journal of Social Psychiatry, 64(1), pp.73-79.