Medium and long-term efficacy of psychoeducational family intervention for bipolar I disorder: Results from a real-world, multicentric study.

OBJECTIVES: This study aims to explore the long-term efficacy of a psychoeducational family intervention (PFI) in bipolar I disorder at one and five years post-intervention in terms of improvement of: (1) patients' symptoms and global functioning and (2) relatives' objective and subjective burden and coping strategies. METHODS: This is a multicentre, real-world, controlled, outpatient trial. Recruited patients and key-relatives were consecutively allocated to the experimental intervention or treatment as usual. Patients were assessed at baseline, and after one and five years. RESULTS: One hundred and thirty-seventh number families have been recruited; 70 have been allocated to the experimental intervention, and 67 have been allocated to the control group. We observed an increasing positive effect of the PFI on patients' clinical status, global functioning and objective and subjective burden after one year. We also found a reduction in the levels of relatives' objective and subjective burden and a significant improvement in the levels of perceived professional support and of coping strategies. The efficacy of PFI on patients' clinical status was maintained at five years from the end of the intervention, in terms of relapses, hospitalizations and suicide attempts. CONCLUSIONS: The study showed that the provision of PFI in real-world settings is associated with a significant improvement of patients' and relatives' mental health and psychosocial functioning in the long term. We found that the clinical efficacy of the intervention, in terms of reduction of patients' relapses, hospitalization and suicide attempts, persists after 5 years. It is advisable that PFI is provided to patients with BD I in routine practice.

Views of persons with schizophrenia on their own disorder: an Italian participatory study.

OBJECTIVE: This study explored the views of 241 patients with schizophrenia about their own disorder. METHODS: Patients' knowledge of their diagnosis, confidence that they will be well again, and perception of limitations in their own life as a result of the disorder were explored in relation to patients' opinions about the social consequences of schizophrenia. Study results were presented to participants, and suggestions were collected regarding how these study results should be used. RESULTS: Seventy-two respondents (30%) reported that a psychiatrist told them that they have schizophrenia. Respondents who were confident that they would be well again had a lower duration of contact with psychiatric services and a less pronounced perception of affective and social difficulties related to schizophrenia. Respondents who did not feel limited in their life by the disorder reported less social distance and more optimism about the usefulness of treatments. CONCLUSIONS: Participatory studies may provide ideas for a more constructive interaction between patients and professionals.

The effects of psychoeducational family intervention on coping strategies of relatives of patients with bipolar I disorder: results from a controlled, real-world, multicentric study.

Background: Psychoeducational family intervention (PFI) has been proven to be effective in improving the levels of family burden and patients' personal functioning in schizophrenia and bipolar disorders (BDs). Less is known about the impact of PFI on relatives' coping strategies in BD. Methods: A multicenter, controlled, outpatient trial funded by the Italian Ministry of Health and coordinated by the Department of Psychiatry of the University of Campania "Luigi Vanvitelli" has been conducted in patients with bipolar I disorder (BD-I) and their key relatives consecutively recruited in 11 randomly selected Italian community mental health centers. We aim to test the hypothesis that PFI improves problem-oriented coping strategies in relatives of BD-I patients compared to the Treatment As Usual (TAU) group. Results: The final sample was constituted of 123 patients and 139 relatives. At baseline assessment (T0), the vast majority of relatives already adopted problem-oriented coping strategies more frequently than the emotion-focused ones. At the end of the intervention, relatives receiving PFI reported a higher endorsement of adaptive coping strategies, such as "maintenance of social interests" (odds ratio [OR]=0.309, CI=0.04-0.57; p=0.023), "positive communication with the patient" (OR=0.295, CI=0.13-0.46; p=0.001), and "searching for information" (OR=0.443, CI=0.12-0.76; p=0.007), compared to TAU relatives, after controlling for several confounders. As regards the emotion-focused coping strategies, relatives receiving the experimental intervention less frequently reported to adopt "resignation" (OR=-0.380, CI=-0.68 to -0.08; p=0.014) and "coercion" (OR=-0.268, CI=-0.46 to -0.08; p=0.006) strategies, compared to TAU relatives. Conclusion: PFI is effective in improving the adaptive coping strategies of relatives of BD-I patients, but further studies are needed for evaluating the long-term benefits of this intervention.

Social network in long-term diseases: a comparative study in relatives of persons with schizophrenia and physical illnesses versus a sample from the general population.

This study compares the social network of a sample of 709 relatives of patients with schizophrenia, 646 relatives of patients with physical diseases, and 714 lay respondents, recruited in 30 randomly selected Italian areas, stratified for geographic location and population density. Each respondent was asked to fill in the Social Network Questionnaire. The social network was less extended and supportive in relatives of patients with schizophrenia than in those of patients with physical diseases and in the general population. Multivariate analyses revealed that social contacts were similarly reduced in relatives of patients with schizophrenia and physical diseases, while social support was significantly lower in relatives of patients with schizophrenia than in the other two groups. Social resources were higher in young respondents and in those living in rural areas. These results highlight the need to provide the families of those with long-term diseases with interventions aimed at increasing their social resources.

Implementing psychoeducational interventions in Italy for patients with schizophrenia and their families.

OBJECTIVE: This study explored the feasibility of providing psychoeducational interventions for persons with schizophrenia and their families. METHODS: The study was carried out in 23 Italian mental health centers. Two professionals from each center attended three monthly training sessions on psychoeducational interventions. After the training, each professional provided informative sessions on schizophrenia to five families of service users with schizophrenia, which consisted of three meetings with each family on clinical aspects of schizophrenia, drug treatments, and detection of early signs of relapse. Each professional then provided the intervention to families for six months. RESULTS: Thirty-eight of the 46 participants completed the training course, and 34 provided the intervention to 71 families. Twenty-nine of the 34 provided the entire intervention to the families and five of the 34 held only informative sessions on schizophrenia. Ninety-one percent of the participants who completed the study reported difficulties in integrating the intervention with their other work responsibilities, and 96 percent acknowledged the positive effect that the intervention had on the center's relationship with patients with schizophrenia and their families. CONCLUSIONS: These results support the idea that it is possible to introduce psychoeducational interventions in mental health services after a relatively brief period of training and supervision.

Patient functioning and family burden in a controlled, real-world trial of family psychoeducation for schizophrenia.

OBJECTIVE: This study explored the effectiveness of a psychoeducational family intervention for schizophrenia on patients' personal and social functioning as well as on relatives' burden and perceived support. METHODS: Thirty-four mental health professionals from 17 public mental health centers in Italy selected 71 families of consumers with schizophrenia. Forty-two families were randomly assigned to a group that received the intervention for six months, and 29 families were assigned to a waiting list for six months. At baseline and six months later, validated tools were used to assess patients' clinical status, personal and social functioning, and social network as well as relatives' burden, social resources, and perception of professional support. RESULTS: In the intervention group the number of patients with poor or very poor global personal and social functioning decreased significantly, from 17 (47 percent) at baseline to nine (25 percent) at follow-up. A significant improvement was found for the intervention group in patients' social relationships, interests in obtaining a job, maintenance of social interests, and management of social conflicts. Twenty-seven patients (74 percent) reported that their social relationships had improved during the six-month period. For both the intervention and control groups, family burden significantly improved. Relatives' social contacts and perception of professional support significantly increased only in the intervention group. CONCLUSIONS: The results suggest that a psychoeducational family intervention may have a significant impact on functional outcomes of schizophrenia when provided to patients and caregivers in real-world settings.

Family burden in long-term diseases: a comparative study in schizophrenia vs. physical disorders.

This study explored burden and social networks in families of patients with schizophrenia or a long-term physical disease. It was carried out in 169 specialised units (mental health department, and units for the treatment of chronic heart, brain, diabetes, kidney, lung diseases) recruited in 30 randomly selected geographic areas of Italy. The study sample consisted of 709 key relatives of patients with a DSM-IV diagnosis of schizophrenia and 646 key relatives of patients with physical diseases. Each relative was asked to fill in the Family Problems Questionnaire (FPQ) and the Social Network Questionnaire (SNQ). In all selected pathologies, the consequences of caregiving most frequently reported as always present in the past 2 months were constraints in social activities, negative effects on family life, and a feeling of loss. Objective burden was higher in brain diseases, and subjective burden was higher in schizophrenia and brain diseases than in the other groups. Social support and help in emergencies concerning the patient were dramatically lower among relatives of patients with schizophrenia than among those of patients with physical diseases. In the schizophrenia group, both objective and subjective burden were significantly higher among relatives who reported lower support from their social network and professionals. The results of this study highlight the need to provide the families of those with long-term diseases with supportive interventions, including: (a) the management of relatives' psychological reactions to patient's illness; (b) the provision of information on the nature, course and outcome of patient's disease; (c) training for the relatives in the management of the patient's symptoms; and (d) the reinforcement of relatives' social networks, especially in the case of schizophrenia.

Efficacy of psychoeducational family intervention for bipolar I disorder: A controlled, multicentric, real-world study.

BACKGROUND: This study assessed the efficacy of the Falloon model of psychoeducational family intervention (PFI), originally developed for schizophrenia management and adapted to bipolar I disorder. The efficacy of the intervention was evaluated in terms of improvement of patients׳ social functioning and reduction of family burden. METHODS: This was a multicentre, real-world, controlled, outpatient trial carried out in 11 randomly recruited Italian mental health centres. Enroled patients and key-relatives were consecutively allocated either to receive PFI and Treatment As Usual (TAU) or to a waiting list receiving TAU alone. The efficacy of the intervention was evaluated in terms of improvement in patients׳ social functioning (primary outcome) and reduction of family burden (secondary outcome). RESULTS: Of the 137 recruited families, 70 were allocated to the experimental group and 67 to the control group. At the end of the intervention, significant improvements in patients׳ social functioning and in relatives׳ burden were found in the treated group compared to TAU. This effect of the intervention remained also after controlling for several confounding patient׳s socio-demographic and clinical factors. The experimental intervention had an impact also on other outcome measures, such as patients׳ clinical status and personal burden. LIMITATIONS: Lack of an active control group. CONCLUSIONS: The results of this study clearly show that the psychoeducational family intervention according to the Falloon model is effective in improving the social outcome of patients with bipolar I disorder.

The effect of social network on burden and pessimism in relatives of patients with schizophrenia.

The authors explored the social network of caregivers of patients with schizophrenia in relation to relatives' sociodemographic characteristics, patients' clinical variables, family burden, and pessimism about the consequences of the disease. They evaluated 709 key relatives of patients with schizophrenia concerning the above-mentioned variables by means of well-validated questionnaires. A more supportive social network was found in relatives who reported lower levels of burden and pessimism about schizophrenia. The effect of social network on relatives' burden and opinions about schizophrenia was significantly different in relation to relatives' gender. Strengthening the relatives' social network may represent a useful strategy to alleviate their burden and pessimism about schizophrenia.

Beliefs of psychiatric nurses about schizophrenia: a comparison with patients' relatives and psychiatrists.

BACKGROUND: What patients' relatives and health professionals think about causes, treatments and psychosocial consequences of schizophrenia can influence its detection and outcome. AIMS: To compare the beliefs about schizophrenia in 190 nurses, 110 psychiatrists and 709 relatives of patients with this mental disorder, recruited in 30 randomly selected mental health centres. METHODS: In each centre, the key-relatives of the first consecutive 25 subjects with schizophrenia, and the nurses and psychiatrists who had been working in the service for at least one year, were asked to complete the Questionnaire on the Opinions about Mental Illness (QO). RESULTS: The factors most frequently mentioned by psychiatrists and nurses among the causes of schizophrenia were heredity, stress and family conflicts, while those most frequently mentioned by relatives were stress, traumas and love breakdown. Nurses had opinions: (a) similar to those expressed by psychiatrists concerning patients' ability to work equally as other people, and patients' punishability in case of illegal acts; (b) similar to those expressed by relatives about patients' unpredictability and political rights; (c) significantly different from the other two samples as concerns recognition of patients' affective rights. CONCLUSIONS: Family psychoeducational interventions and nurses' training should address not only clinical aspects but also disability and psychosocial consequences of schizophrenia.

A 'family affair'? The impact of family psychoeducational interventions on depression.

Major depressive disorder is reported to be the most common mental disorder, and one of the leading causes of disability-adjusted life years. It causes high levels of family burden and of expressed emotions. Research interest in family functioning in mental disorders has recently shifted from schizophrenia to unipolar and bipolar affective disorders. However, studies on family burden and on the effect of family psychoeducational interventions on major depression are still very few in number and lack a rigorous methodology, clear outcome measures and adequate follow-ups. Despite this, the few available studies on the efficacy of psychoeducational family intervention in unipolar major depression have had promising results. A comprehensive management of unipolar major depression should include psychoeducational family intervention.

What people with schizophrenia think about the causes of their disorder.

AIMS: To describe what users with schizophrenia think about the causes of their disorder. METHODS: In each of the 10 participating Italian mental health centres, 25 users with schizophrenia were consecutively recruited and asked to complete the Users' Opinions Questionnaire (UOQ). RESULTS: 150 out of 198 respondents mentioned at least one social cause for their mental disorder, and 114 reported exclusively social causes. Family conflicts were the most frequently reported social cause (21%), followed by traumas (20%), work and study difficulties (17%), and psychological disturbances (17%). Ten percent of the respondents mentioned biological causes. Biological causes were more frequently reported by users who were aware of their diagnosis of schizophrenia, whereas social causes by those who just knew they suffered from a psychosis. Difficulties in social relationships were more frequently pointed out by respondents with an earlier onset of the illness and a higher number of compulsory admissions in the previous 12 months. These users expressed more scepticism about the usefulness of the treatments they received, and perceived a greater social distance. CONCLUSIONS: Users' beliefs about the causes of their disorder should be taken into account by psychiatrists in order to improve their working alliance with them.

Development and validation of a self-reported questionnaire on users' opinions about schizophrenia: a participatory research.

BACKGROUND: Although users' involvement in mental health research has repeatedly been acknowledged as having a positive influence on research quality, this rarely happens. AIMS: To develop and validate a Questionnaire on Users' Opinions (QOU) about schizophrenia, in close collaboration with 279 persons affected by this disorder. METHODS: A preliminary list of items concerning the opinions of users with schizophrenia regarding causes, treatments and psychosocial consequences of the disorder was developed by 38 users with schizophrenia and 40 professionals who attended a workshop. Psychometric properties of the QOU were tested on 241 users with schizophrenia, 149 of whom were randomly assigned to a test-retest study and 92 to a face-validity study. Content and construct validity were explored in the whole sample. RESULTS: The final version of the QOU contains: (1) 24 items on the psychosocial consequences of schizophrenia, grouped into six subscales, whose Cronbach's alpha ranged between 0.55 and 0.74; (2) five multiple choice items on the Italian psychiatric law; (3) 12 open questions; and (4) four yes/no skipping items. Items' reliability, measured by Cohen's kappa coefficient, ranged between 0.55 and 0.92. CONCLUSION: This questionnaire may be useful to assess patients' beliefs about schizophrenia and to target psychosocial interventions for this mental disorder.

Family burden in bipolar disorders: results from the Italian Mood Disorders Study (IMDS).

AIMS: To explore: a) the burden of care, and the professional and social support in relatives of patients with bipolar disorders; b) the psychosocial interventions provided to patients and their families by Italian mental health centres. METHODS: 342 outpatients with a bipolar disorder and their key-relatives were randomly recruited in 26 Italian mental health centres, randomly selected and stratified by geographical area and population density. Family burden was explored in relation to: a) patient's clinical status and disability; b) relatives' social and professional support; c) interventions received by patients and their families; d) geographical area. RESULTS: In the previous two months, global functioning was moderately impaired in 36% of the patients, and severely impaired in 34% of them. Twenty-one percent of patients attended a rehabilitative programme, and 3% of their families received a psychoeducational intervention. Burden was higher when patient's symptoms and disability were more severe, the relatives had poorer psychological support and help in emergencies by the social network, and the family lived in Southern Italy. Differences in family burden in relation to geographical area disappeared when psychosocial interventions were provided. CONCLUSION: This study highlights the need to increase the availability of rehabilitative interventions for patients with bipolar disorders and of psychological support for their families, especially in Southern Italy.

[Family psychoeducational interventions for schizophrenia in routine settings: impact on patients' clinical status and social functioning and on relatives' burden and resources]. / Interventi psicoeducativi familiari per la schizofrenia nella pratica clinica: effetto sullo stato clinico e la disabilità dei pazienti e sul carico e le risorse familiari.

OBJECTIVE: This study explored the effectiveness of a psychoeducational family intervention for schizophrenia on patients' clinical status and disability and relatives' burden and perceived support. METHODS: The study has been carried out in 17 mental health centres. In each of them, 2 professionals were trained in a psychoeducational intervention and applied it for six months with families of users with schizophrenia. At baseline and six months later, patients' clinical status and disability, and relatives' burden, social network and professional support were assessed by validated tools. RESULTS: Of the seventy-one recruited families, 48 (68%) completed the intervention. At six months, a significant improvement was found in patients' clinical status and social functioning, as well as in relatives' burden and social and professional support. In particular, the percentage of patients with poor or very poor global social functioning dropped from 50% to 27% at six months. Forty percent of patients and 45% of relatives reported a significant improvement in their social contacts over the intervention period. CONCLUSIONS: The results of this study confirm the hypothesis that psychoeducational family interventions may have a significant effect on social outcome and family burden in schizophrenia when provided in routine conditions.

[Benefits and difficulties in implementing family psychoeducational interventions for schizophrenia in mental health services: results from a multicentre Italian study]. / Aspetti positivi e difficoltà nella diffusione degli interventi psicoeducativi familiari nella pratica clinica: uno studio multicentrico in 23 CSM italiani.

AIMS: This study aims to explore: a) the feasibility of psycho-educational interventions for families of users with schizophrenia in clinical practice by trained staff; b) the benefits and problems encountered by professionals in the use of these interventions. METHODS: 46 professionals from 23 Italian Mental Health Services (MHS) attended at a three-module training course in psycho-educational interventions and four supervisions in the subsequent year. Following the course, participants provided the intervention to families of users with schizophrenia. The difficulties and benefits encountered by trainees to use the intervention were registered on the Famnily Intervention Schedule. RESULTS: 83% of the participants completed the training course. Following the course, the intervention started in 71 families from 17 MHS. 76% of trainees provided the intervention to 2-5 families, while 13% of them only held informative sessions on schizophrenia. During the supervision period, the organisational difficulties experienced by the professionals were stable, while the benefits increased. Differences in benefits and difficulties were detected in relation to the trainees' experience and professional roles. CONCLUSIONS: It is possible to introduce psycho-educational interventions in MHS after a relatively brief period of training and supervision of the staff. Organisational difficulties need to be addressed to increase the dissemination of these interventions on a large scale.

Perception of patients' unpredictability and beliefs on the causes and consequences of schizophrenia- a community survey.

BACKGROUND: The belief that mental disorders involve a high risk of unpredictable behaviours is a factor which influences negatively the social acceptance of the mentally ill. In this paper, we compare the beliefs about the causes and psychosocial consequences of schizophrenia expressed by 536 respondents who had the firm conviction that patients with schizophrenia are unpredictable and by 457 respondents who firmly believed that they are not. METHODS: The survey was conducted in 30 Italian geographic areas, randomly selected taking into account their location and population density. The data were collected by the Questionnaire about Opinions on Mental Illness (QO). RESULTS: Respondents who believed that patients with schizophrenia are unpredictable reported more frequently factors such as use of alcohol and drugs and frequenting bad company as being involved in the development of the disorder. In addition, this group showed more restrictive opinions about patients' civil and affective rights. Low education was found to be significantly associated with perception of "unpredictability" in schizophrenia. CONCLUSIONS: These results suggest the need to: a). inform the general public on the main clinical characteristics of schizophrenia and on the risk of unpredictable behaviours in the acute phases of this mental disorder; b). carry out sensitisation campaigns against discrimination toward people with schizophrenia emphasising successful experiences of social integration.

[Burden, attitudes and social support in the families of patients with long-term physical diseases]. / Carico, atteggiamenti e sostegno sociale nelle famiglie dei pazienti con malattie fisiche di lunga durata.

AIMS: To describe in a sample of 646 relatives of patients with physical long-term illnesses: a) the relatives' burden of care; b) the relatives' attitudes towards the patients; c) the social and professional support received by the families. METHODS: The study has been carried out in 30 Italian geographic areas randomly selected taking into account geographic location and population density. The sample has been consecutively recruited in 139 specialised units for the treatment of chronic heart, brain, diabetes, kidney, and lung diseases. Family burden was evaluated in relation to: a) family's socio-demographic variables and patients' clinical variables; b) relatives' attitudes toward the patient; c) social and professional support; d) geographic area and population density. OUTCOME MEASURES: Family Problems Questionnaire, physical illness version (QPF-O) and Social Network Questionnaire (QRS). RESULTS: The consequences of caregiving most frequently reported were constraints in social and recreational activities, and feelings of loss. Burden was more marked in relatives of patients with higher physical disabilities, with neurological illnesses, and in relatives with lower support by their social network. CONCLUSIONS: These data highlight the need to provide psychological and practical support to caregivers of patients with long-term physical diseases on the basis of the evaluation of their needs for care.

Beliefs about schizophrenia in Italy: a comparative nationwide survey of the general public, mental health professionals, and patients' relatives.

OBJECTIVE: This study compared beliefs about the causes, treatments, and psychosocial consequences of schizophrenia in a sample of 714 lay respondents, 465 mental health professionals, and 709 key relatives of patients with this disorder. METHOD: We conducted the survey in 30 Italian geographic areas that we randomly selected after considering location and population density. We used the Questionnaire on the Opinions About Mental Illness (QO) to collect data. RESULTS: Of those surveyed, 34% of the lay respondents, 20% of the professionals, and 68% of the relatives stated that schizophrenia is exclusively caused by psychosocial factors. Lay respondents' opinions on patients' civil rights and social competence tended to be more similar to those expressed by professionals then to those reported by relatives. Lay respondents differed from the other 2 groups in their beliefs regarding the effectiveness of psychological treatments, patients' unpredictability, and whether patients should be admitted to asylums. CONCLUSIONS: These results suggest that the general public needs to be better informed about schizophrenia's main characteristics, available treatments, and risk for dangerous behaviours. The existing gap among the study's target populations could be reduced through campaigns aimed at increasing public awareness of the affective and civil rights of patients.

[Psychosocial causes and consequences of schizophrenia: opinions of Italians]. / Cause e conseguenze psicosociali della schizofrenia: le opinioni degli Italiani.

OBJECTIVE: Description of opinions on schizophrenia and its psychosocial consequences in a sample of general population. METHODS: The study has been carried out in 29 GP units stratified by geographic area and population density of their catchment areas and randomly selected. Each respondent was asked to read a case-vignette describing a patient who met ICD-10 criteria for schizophrenia, and then to fill the Questionnaire on the Opinions about Mental Illness--General Population's version (QO-GP). RESULTS: Data on 714 respondents were collected. 21% of the sample identified a case of schizophrenia, 66% of depression/anxiety disorder, and 13% of "nervous breakdown". Factors most frequently mentioned as causes of detected disorder were stress (72%), heredity (62%), family difficulties and psychological traumas (45%). More pessimistic opinions about psychosocial consequences of schizophrenia were found among respondents with lower educational level and older age. Respondents who referred the case-vignette to schizophrenia reported more pessimistic opinions about psychosocial consequences of detected disorder. CONCLUSIONS: The results of this study outline the need to plan educational campaigns on mental illnesses, which take into account the socio-cultural characteristics of the target populations.