Family therapy may cut relapse rates in schizophrenia

Last Updated: 2010-11-10 19:36:05 -0400 (Reuters Health)

By Karla Gale

NEW YORK (Reuters Health) - Family interventions that curb negative emotions might help schizophrenic patients avoid relapse, primarily by promoting medication compliance, according to a new Cochrane systematic review.

Compared to standard care with medications, therapy that reduced negative emotions against the schizophrenic member of the family reduced relapses by 45% and hospitalizations by 22%, while increasing medication compliance by 40%, according to lead author Dr. Fiona Pharoah and associates.

"I see this as further validation of the potential impact family psychoeducation can have, beyond what medication can do to reduce relapse and hospitalizations," said Dr. Lisa Dixon, professor of psychiatry at the University of Maryland School of Medicine, Baltimore, who was not involved in this research.

"The real question now is why it isn't used more widely," she added.

Relapses are more frequent in schizophrenia when families are critical, hostile, or overly involved, the authors explain. The goals of family psychosocial interventions are to reduce levels of expressed emotion, stress and family burden while improving problem-solving skills.

Dr. Pharoah, from Buckinghamshire Mental Health NHS Foundation Trust, High Wycombe, UK, and her team updated previous reviews by searching the Cochrane Schizophrenia Group Trials Register. Ultimately they analyzed data from 53 randomized or quasi-randomized studies involving 4708 patients treated in community settings. Patient age ranged from 16 to 80.

Studies had been conducted in Australia, Canada, Europe, China, and the US, with interventions ranging from six weeks to three years. Control groups received standard care that included medication.

The evidence suggests that family interventions significantly reduced hospital admission at one year. In eight trials with 481 families, the relative risk of hospitalization was 0.78, with a number needed to treat (NNT) of 8.

Similarly, family therapy reduced relapses at one year in 32 trials of 2981 families (RR 0.55, NNT = 7). Significant reductions were still evident at 18 and 24 months.

Family interventions increased medication compliance in 10 trials of 695 families (RR 0.60, NNT 6). The authors suggest that "it is by this means that family intervention has its main effect."

Economic analyses in three studies showed net savings in direct or indirect costs with family interventions, "a consistent and important finding."

In studies reporting death as an outcome, interventions made no difference in suicide rates. Results were equivocal for employment, independent living, and imprisonment.

There's plenty of evidence that family interventions work, Dr. Dixon told Reuters Health. The problem now is the many barriers to implementation, including lack of reimbursement, lack of provider-level training, and knowing what services family and patients most need and want.

For instance, she said, "There is a lot of misunderstanding about patient confidentiality. It's appropriate to be sensitive, but it behooves us as professionals to know what the rules are and how to meet family needs while respecting those rules."

There are also alternatives to clinic-based interventions, she noted, such as the free "family-to-family peer-support program from the National Alliance on Mental Illness, and other kinds of support groups and information sessions NAMI and mental health systems provide."

The paper notes that the quality of reporting in most studies was so poor that "the outcomes in this review may be biased with an overestimate of effect."

In a press statement, co-author Dr. John Rathbone, from the University of Sheffield, UK, adds, "We still need a better designed large study to settle arguments about this widely used therapy."

Dr. Dixon disagrees. "We don't need another study to validate that family psychoeducation is effective in preventing relapse, reducing family burden, and improving patient and family functioning."

"With schizophrenia in particular, families may often assume some responsibilities as care providers," she added. "They should be provided with credible, evidence-based tools for optimal outcomes."


Cochrane Library 2010.

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