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QUESTION: In patients with schizophrenia, does patient education improve knowledge, compliance, relapse, symptoms, social function, insight, and satisfaction?
Studies were identified by searching Medline (1966–97), EMBASE/Excerpta Medica (1987–97), PsycLIT (1974–96), and CINAHL (1982–97) and by scanning reference lists of relevant articles.
Studies were selected if they were randomised controlled trials (RCTs) of patient education in patients with schizophrenia (category A). Supplementary data were taken from naturalistic studies of patient education in patients with schizophrenia (category B) and RCTs of patient education in mixed samples (category C). Studies were excluded if they used complex interventions involving mainly social skills training and psychotherapy, or family intervention with educational programmes.
Data were extracted on patient characteristics, type of intervention, number of sessions, length of follow up, results, and study methods.
7 RCTs (category A), 4 naturalistic studies (category B), and 8 RCTs (category C) met the selection criteria. The 7 category A RCTs had sample sizes of 20–236 patients (mean 82 patients). Follow up ranged from 3 weeks to 2 years. 3 RCTs included an element of training that ranged from a 1 hour counselling intervention on how to tailor the prescribed regimen to a medication module for 3 hours weekly for 2–3 months. 1 RCT had a brief training element on relapse prevention. 1 RCT compared behavioural training with didactic methods. The other 2 RCTs used only didactic methods (1 hour to 25 hours weekly for 3 wks). The 8 category C RCTs had sample sizes of 28–418 patients (mean 95 patients). Follow up ranged from 2 weeks to 6 months. In 5 RCTs, the diagnoses were not reported; in 2 RCTs, the proportions of patients with schizophrenia were 42% and 65%. 1 RCT reported that the diagnoses were “mainly” schizophrenia. 6 RCTs used group information together with discussion of medication issues (1 RCT), reinforcement (1 RCT), role play (1 RCT), and discussion on tardive dyskinesia (1 RCT). 1 RCT compared an information sheet only with an information sheet and verbal explanation, and 1 RCT used individual information and problem identification combined with compliance planning and problem solving. Most studies showed an improvement in knowledge (5 of 6 RCTs in category A and 5 of 6 RCTs in category C). Results for other outcomes were mixed: a treatment benefit was shown for compliance in 2 of 5 RCTs (category A) and 3 of 5 RCTs (category C); for relapse in 1 of 3 RCTs (category A) and 1 of 3 RCTs (category C); for symptoms in 2 of 5 RCTs (category A) and 1 of 1 RCT (category C); for social function in 2 of 4 RCTs (category A); for insight in 1 of 2 RCTs (category A); for quality of life in 1 of 1 RCT (category A); and for satisfaction in 1 of 1 RCT (category A) and 0 of 1 RCT (category C).
In patients with schizophrenia, patient education is effective for improving knowledge. Results for compliance, relapse, symptoms, social function, insight, quality of life, or satisfaction are not conclusive.
Evidence is increasing for the efficacy of psychosocial interventions in schizophrenia, and some patients (and families) prefer them over medications.1 There can, however, be difficulties with implementation in everyday clinical practice where resources are scarce, trained staff may not be available or may not have the time to see many patients, and providing such interventions over many years is different from being part of a team doing a randomised controlled trial. Indeed, variations in precisely what is given, by whom, and where and when may account for some of the inconsistencies in these studies. Many of the approaches combine overlapping elements, and if we knew what worked for which patients, it might be easier to provide a service.
Barbato and D'Avanzo in their review of family interventions replicate and extend an earlier version of an existing Cochrane review.2 They show that family interventions reduce relapse rates but also highlight several recent studies that have failed to find this. Many reasons are possible for this finding, but the most likely is that more recent studies are better controlled for non-specific therapeutic elements. The other possibilities worth mentioning are that earlier studies may have included more families with “high expressed emotion” or that patients just spend less time with their families than they used to. They also show that at least some of the effect of family intervention is to increase compliance with medication.
Barbato and D'Avanzo suggest that family interventions should provide information about the illness, include the patient, and be long term to have long term benefits. The latter result could reflect an important dose response effect. Alternatively, it may mean that non-specific therapeutic elements such as long term support are as important as anything else. The latter interpretation is compatible with what families actually say is beneficial about these approaches.3
The review by Merinder is arguably a more important contribution because it focuses on one element of many psychosocial interventions—psychoeducation, although I don't see why it can't be called “education.” Information certainly appears to increase knowledge, but it is less clear that it changes attitudes to the illness or its treatment, improves compliance, or reduces relapse. The Cochrane review and meta-analysis of 10 of the RCTs included here, however, finds an overall effect on relapse.4 There is also one rather curious finding in the Merinder review, which may have substantial clinical relevance.
It appears that short (<10 sessions) and long interventions have no differential effect on improving knowledge or compliance. This could mean that only a certain amount of information can be given usefully to patients. It is also possible that family intervention effects result from more than just education.
Where does all this leave the practising clinician? The best available evidence shows that various psychosocial interventions can be beneficial in schizophrenia, but that the common elements of information about the illness and long term support may be as good as anything else. Patients clearly need to be involved, and it may only be necessary to involve their family if they are particularly critical or hostile (provided, of course, the patients have contact with them and everyone is amenable to this approach). A rolling group, with intermittent educational sessions, may be all that is required. It should be borne in mind that any effective intervention can have adverse effects and information could conceivably reduce morale and increase hopelessness. Finally, perhaps the greatest service one could give to one's patients and the global community of patients and clinicians would be to routinely audit the implementation of an approach, ask the patients and relatives to indicate what they find useful, and publish the results.
Source of funding: no external funding.
For correspondence: Dr L B Merinder, Department of Psychiatric Demography, Institute for Basic Psychiatric Research, Psychiatric Hospital in Aarhus, University Hospital, Skovagervej 2, DK-8240 Risskov, Denmark. Fax +45 77 89 28 99.
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