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A needs based cognitive behavioural family intervention for schizophrenia reduced relapse in the long term
  1. William Bradshaw, PhD
  1. University of Minnesota; Saint Paul, Minnesota, USA

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QUESTION: In outpatients with schizophrenia and their caregivers, does a needs based family intervention reduce relapse and caregivers' needs in the long term?

Design

Randomised (unclear allocation concealment)*, blinded (outcome assessors)*, controlled trial with 12 months of follow up.

Setting

South Manchester, UK.

Patients

79 patient–caregiver dyads. Patients were 18–65 years of age (mean age 36 y, 65% men); met ICD-10 criteria for schizophrenia, schizoaffective disorder, or delusional disorder; had ≥1 relapse of psychotic symptoms leading to inpatient admission in the previous 2 years; had ≥2 years of illness (mean duration 13 y); and had ≥10 hours of face to face contact with a caregiver each week over the previous month. Follow up was 80% for patients at 1 year and 88% for caregivers at 6 months.

Intervention

After stratification by sex, patient–caregiver pairs were allocated to standard care plus a family intervention (n=39) or standard care alone (n=40) for 24 weeks. Standard care consisted of psychiatric management by a clinical team, maintenance neuroleptic medication, monitoring through outpatient and community follow up, and the care programme approach to case management. The family intervention consisted of 10–20 treatment sessions of cognitive behavioural family interventions based on needs identified by caregivers through systematic assessment. 3 broad areas of intervention were given: problem solving techniques, cognitive behavioural intervention for families, and cognitive behavioural interventions for patients to reduce psychotic symptoms.

Main outcome measures

Relapse at 1 year and number of needs identified by caregivers (Relatives' Cardinal Needs Schedule).

Main results

Analysis was by intention to treat. Fewer patients in the intervention group than in the control group had relapses (p=0.003) or relapses that did not require hospital admission (p=0.003) (table). Hospital admission did not differ between groups (table). The groups did not differ for the number of caregivers' cardinal needs at 6 months; <80% of caregivers were assessed at 12 months.

Family intervention plus standard care v standard care alone (control) for schizophrenia†

Conclusion

A needs based cognitive behavioural family intervention for patients with schizophrenia and their caregivers was better than standard treatment for reducing relapse at 1 year. The groups did not differ at 6 months for number of needs identified by caregivers.

Commentary

People with schizophrenia and other psychotic disorders have high rates of relapse and hospital readmission, which can lead to increased healthcare use and poor response to monotherapies. Although antipsychotic medications are frequently helpful in reducing psychotic symptoms and relapse, >70% of clients are non-compliant with medication and up to 50% have persistent psychotic symptoms even when adhering to pharmacological treatment.1

Psychosocial interventions such as family psychoeducational treatment have proven effectiveness in reducing relapse in people with schizophrenia. Similarly, cognitive behavioural treatment (CBT) is an emerging treatment that is effective in reducing psychotic symptoms and relapse. The study by Sellwood et al is the first to evaluate the effect of an innovative treatment model that combines family intervention with cognitive behavioural methods. Sellwood et al found an advantage for their combined family intervention over standard care that included medication and case management. Clients in this study appear representative of long term clients with schizophrenia (mean length of illness 13 y). An additional strength of this study is the high follow up rate at 1 year. The groups did not differ in the number of caregiver needs identified at 6 and 12 months. This may be because of the lower response rate of caregivers at 12 months. It also may be that it takes more than 12 months to reduce the needs of those who care for people with a severe and persistent illness. The family intervention provides a new model of treatment uniquely suited to patients who live with family or maintain family ties. It incorporates recent innovations in CBT for people with schizophrenia with family interventions to meet the needs of family members.

The family intervention described in this study offers the potential to reduce the emotional and economic costs of relapse in schizophrenia. The promising results need to be replicated. Future research would benefit from the addition of other measures of patient and family outcome. As research supporting the efficacy and effectiveness of this intervention expands, this model could be adopted into existing mental health programmes. Dissemination of the treatment manual and protocol could facilitate the further training of mental health professionals and encourage evaluation of the method in other countries.

References

View Abstract

Footnotes

  • Source of funding: National Health Service Executive North West and Research and Development Funds from Tameside and Glossop Community and Priority Care Trust.

  • For correspondence: Dr C Barrowclough, Tameside General Hospital, Ashton under Lyne, UK. christine.barrowclough{at}man.ac.uk

  • * See Glossary.

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