Psychoeducation efficacy in bipolar disorders: beyond compliance enhancement. Patient and relative education in community psychiatry: a randomized controlled trial regarding its effectiveness. A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Medication and symptom management education program for the rehabilitation of psychiatric patients in Korea: the effects of promoting schedule on self-efficacy theory. Effectiveness of psychoeducational intervention for rural Chinese families experiencing schizophrenia--a randomised controlled trial. A pilot study evaluating the effectiveness of individual inpatient cognitive-behavioural therapy in early psychosis. Cognitive--behavioural therapy and family intervention for relapse prevention and symptom reduction in psychosis: randomised controlled trial. Psychoeducation in schizophrenia: 7-year follow-up concerning rehospitalization and days in hospital in the Munich Psychosis Information Project Study. Multiple-family groups and psychoeducation in the treatment of schizophrenia. Psychoeducational psychotherapy for schizophrenic patients and their key relatives or care-givers: results of a 2-year follow-up. [Psychoeducational-psychotherapeutic treatment of schizophrenic patients and their caregivers. Results of a 1-year catamnestic study]. Outcomes of an effectiveness trial of cognitive-behavioural intervention by mental health nurses in schizophrenia.
Several previous studies have established that low treatment adherence is common among bipolar patients and may explain high rates of recurrence. On the other hand, some patients keep relapsing even when they strictly follow their prescribed somatic treatments. Psychological interventions such as psychoeducation may foster early recognition of prodromal symptoms and minimize the risk of relapse. To date, studies assessing the usefulness of psychoeducation in fully compliant patients are lacking.
                This was a single-blind, randomized, prospective clinical trial on the efficacy of group psychoeducation in remitted fully compliant DSM-IV bipolar I patients (N = 25) who were compared with a group with similar characteristics (N = 25) who did not receive psychoeducation. All patients received naturalistic pharmacologic treatment. Recruitment began in 1997 and follow-up was completed in January 2002. The follow-up phase comprised 2 years during which all patients continued receiving naturalistic treatment without psychological intervention and were assessed monthly on several outcome measures.
                At the end of the 2-year follow-up, 23 subjects (92%) in the control group fulfilled criteria for recurrence versus 15 patients (60%) in the psychoeducation group (p < .01). The number of total recurrences and the number of depressive episodes were significantly lower in psychoeducated patients.
                Although the present study has the limitation of small sample size, psychoeducation showed its efficacy in preventing relapses in bipolar I patients who were adherent to drug treatment. The action of psychoeducation seems to go beyond compliance enhancement and may support a tripod model composed by lifestyle regularity and healthy habits, early detection of prodromal signs followed by prompt drug intervention, and finally treatment compliance. Family psychoeducation has a well-documented effect on the short-term prognosis in schizophrenia. Less is known about the effectiveness of shorter programmes with the main focus on information for patients (patient education) or for patients and relatives (family education).
                A randomized study of the effectiveness of an eight-session psychoeducational programme for patients with schizophrenia and for their relatives was conducted in two community mental health centres, in Arhus and Viborg (Denmark). Patient outcome measures were knowledge, relapse, compliance, insight and satisfaction, and relative outcome measures were knowledge and satisfaction. Post-intervention outcome and follow-up evaluation 1 year after the start of the intervention are presented.
                A statistically significant increase in knowledge of schizophrenia in both relatives and patients was demonstrated at postintervention and a non-significant trend at 1-year follow-up. Statistically significant changes in the Verona Service Satisfaction Scale Scores in the subdimension of satisfaction with Relatives involvement were demonstrated both for patients and relatives postintervention and for patients at 1-year follow-up. There was a tendency that time-to-relapse increased in the intervention group at postintervention and that the schizophrenia subscore of the Brief Psychiatric Rating Scale was reduced in the intervention group at 1-year follow-up. No differences were found between the groups regarding compliance, insight into psychosis, psychosocial function (General Assessment of Function) or in relatives' expressed emotion scores postintervention or at 1-year follow-up.
                A short patient and relative education programme seems to be able to influence knowledge and some aspects of satisfaction, but does not seem to be sufficient to influence important variables such as relapse, compliance, psychopathology, insight or psychosocial functioning. Studies on individual psychotherapy indicate that some interventions may reduce the number of recurrences in bipolar patients. However, there has been a lack of structured, well-designed, blinded, controlled studies demonstrating the efficacy of group psychoeducation to prevent recurrences in patients with bipolar I and II disorder.
                One hundred twenty bipolar I and II outpatients in remission (Young Mania Rating Scale score <6, Hamilton Depression Rating Scale-17 score <8) for at least 6 months prior to inclusion in the study, who were receiving standard pharmacologic treatment, were included in a controlled trial. Subjects were matched for age and sex and randomized to receive, in addition to standard psychiatric care, 21 sessions of group psychoeducation or 21 sessions of nonstructured group meetings. Subjects were assessed monthly during the 21-week treatment period and throughout the 2-year follow-up.
                Group psychoeducation significantly reduced the number of relapsed patients and the number of recurrences per patient, and increased the time to depressive, manic, hypomanic, and mixed recurrences. The number and length of hospitalizations per patient were also lower in patients who received psychoeducation.
                Group psychoeducation is an efficacious intervention to prevent recurrence in pharmacologically treated patients with bipolar I and II disorder. An effective rehabilitation program was developed for psychiatric patients' self-management of medication and symptoms. The rehabilitation program was designed to allow the patients to understand their illness, cope with their medical regimen, and prevent a relapse by recognizing any of the symptoms when they recur. This study consisted of three phases. The first phase was to explore the extent and the specific mental health needs of psychiatric patients. Data was obtained from 82 subjects who had symptoms of a mental illness including schizophrenia, bipolar disorders, and delusional disorder. They had received medication instruction during their hospitalization. The subjects were at the time outpatients in a psychiatric hospital. In the second phase, the researchers developed an educational program focused on coping with the residual and relapse warning signs, managing the drug side effects, medication compliance, and daily routines, according to the information acquired in the first step. The developed program includes the self-efficacy method reported by Bandura, including manuals and videotapes focusing on real life situations, small group discussions, and telephone coaching. Finally, the researchers investigated the effects of this program. Thirty-eight patients were selected for this study, 18 in the experimental program and 20 as controls. The diagnoses were same as those with the first step. The results showed that the subjects who attended this educational program reported significantly more improvement in self-efficacy (p=0.014) and medication compliance (p= 0.005), and significantly less relapse warning symptom scores (p=0.000) than the controls. In conclusion, these instructional materials will be beneficial for medication and symptom management in rehabilitating psychiatric patients in Korea. In addition, the materials may be a useful psychoeducational resource for professionals in the field of clinical psychiatry. The aim of this study was to explore the characteristics and efficacy of psychoeducational family intervention for persons with schizophrenia in rural China.
                A cluster randomised controlled trial of psychoeducational family intervention for families experiencing schizophrenia (three groups, 326 cases) was conducted in Xinjin County, Chengdu. Treatment groups consisted of family intervention and medication, medication alone, and a control.
                The results showed a gain in knowledge, a change in the relatives' caring attitudes towards the patients, and an increase in treatment compliance in the psychoeducational family intervention group (p < 0.05, 0.001). Most importantly, the relapse rate over 9 months in this group (16.3 %) was half that of the drug-only group (37.8 %), and just over one-quarter of that of the control group (61.5 %) (p < 0.05). Antipsychotic drug treatment and families' attitudes towards patients after the 9-month follow-up were significantly associated with clinical outcome (p < 0.05).
                In rural China, family intervention should focus on improving the relatives' recognition of illness, the caring attitude towards the patients, treatment compliance, relapse prevention, and the training of the patients' social functioning. This trial, one of the largest in the literature, has shown that psychoeducational family intervention is effective and suitable for psychiatric rehabilitation in Chinese rural communities. Recent research indicates that cognitive-behaviour therapy (CBT) can be effective in ameliorating persistent positive symptoms in chronic psychotic patients. The effectiveness of CBT in acute and recent-onset psychosis has been little explored, although a recent pilot study indicated that CBT could significantly improve recovery in acutely psychotic inpatients.
                Short-term individual CBT was compared to supportive counselling/psychoeducation (SC) as an adjunct to standard inpatient hospital care and medication in 21 inpatients experiencing a recent-onset acute schizophrenic episode.
                Both groups showed significant reductions in Brief Psychiatric Rating Scale (BPRS) scores following treatment, although there were no group differences. Time to discharge did not differ significantly between the groups, although there was a greater variance for the SC patients. Two-year follow-up showed no significant differences between the groups, although the number of patients who relapsed, the number of relapses and the time to recurrence of psychotic symptoms was lower in the CBT group than the SC group. Interestingly, the time to readmission was shorter in the CBT group.
                CBT and SC are acceptable treatments for recent-onset acutely psychotic inpatients. A larger randomised controlled trial over multiple hospital sites is warranted. Family intervention reduces relapse rates in psychosis. Cognitive-behavioural therapy (CBT) improves positive symptoms but effects on relapse rates are not established.
                To test the effectiveness of CBT and family intervention in reducing relapse, and in improving symptoms and functioning in patients who had recently relapsed with non-affective psychosis.
                A multicentre randomised controlled trial (ISRCTN83557988) with two pathways: those without carers were allocated to treatment as usual or CBT plus treatment as usual, those with carers to treatment as usual, CBT plus treatment as usual or family intervention plus treatment as usual. The CBT and family intervention were focused on relapse prevention for 20 sessions over 9 months.
                A total of 301 patients and 83 carers participated. Primary outcome data were available on 96% of the total sample. The CBT and family intervention had no effects on rates of remission and relapse or on days in hospital at 12 or 24 months. For secondary outcomes, CBT showed a beneficial effect on depression at 24 months and there were no effects for family intervention. In people with carers, CBT significantly improved delusional distress and social functioning. Therapy did not change key psychological processes.
                Generic CBT for psychosis is not indicated for routine relapse prevention in people recovering from a recent relapse of psychosis and should currently be reserved for those with distressing medication-unresponsive positive symptoms. Any CBT targeted at this acute population requires development. The lack of effect of family intervention on relapse may be attributable to the low overall relapse rate in those with carers. According to most of the relevant guidelines, psychoeducation is considered a basic part of routine therapy for patients with schizophrenia; scientific proofs of its efficacy are based mainly on the results of 1- and 2-year follow-ups. Therefore, the long-term effects of psychoeducation over a period of 7 years were investigated in regard to rehospitalization rates and hospital days.
                Of 101 patients with DSM-III-R or ICD-9 schizophrenia randomly allocated to either an intervention group or a control group between 1990 and 1994, 48 patients were available for follow-up after 7 years. During their index stay, the 24 patients of the intervention group and their key relatives each received a separate psychoeducational group therapy. The 24 patients of the control group received the usual treatment. After index discharge, all 48 patients received a comparable outpatient treatment. Main outcome measures were rehospitalization rate, number of intervening hospital days, compliance, and mean number of consumed chlorpromazine (CPZ) units.
                Seven years after index discharge, the rate of rehospitalization was 54% in the intervention group and 88% in the control group. The rate of rehospitalization per patient was 1.5 in the intervention group and 2.9 in the control group (p < .05). In the intervening period, the mean number of hospital days spent in a psychiatric hospital was 75 in the intervention group and 225 days in the control group. (p < .05). The mean number of consumed CPZ units after 7 years was 354 in the intervention and 267 in the control group.
                Seven years after psychoeducational group therapy, significant effects on the long-term course of the illness can be found. Therefore, the integration of psychoeducation into standard therapy for schizophrenia should become obligatory. To compare outcomes in psychoeducational multiple-family group treatment vs psychoeducational single-family treatment.
                A total of 172 acutely psychotic patients, aged 18 to 45 years, with DSM-III-R schizophrenic disorders were randomly assigned to single- or multiple-family psychoeducational treatment at six public hospitals in the state of New York. Psychotic relapse, symptom status, medication compliance, rehospitalization, and employment were assessed independently during 2 years of supervised treatment.
                The multiple-family groups yielded significantly lower 2-year cumulative relapse rates than did the single-family modality (16% vs 27%) and achieved markedly lower rates in patients whose conditions had not remitted at index hospital discharge (13% vs 33%). The relapse hazard ratio between treatments was 1:3. The relapse rate for both modalities was less than half the expected rate (65% to 80% for 2 years) for patients receiving individual treatment and medication. Rehospitalization rates and psychotic symptoms decreased significantly, and medication compliance was high, to an equal degree in both modalities.
                Psychoeducational multiple-family groups were more effective than single-family treatment in extending remission, especially in patients at higher risk for relapse, with a cost-benefit ratio of up to 1:34. Psychoeducational medication management training (PMT), cognitive psychotherapy (CP) and key-person counselling (KC) were carried out in various combinations in this randomized, controlled intervention study of schizophrenic out-patients (according to DSM-III-R). Special design characteristics of the study were a control group consisting of non-specifically treated patients and a 2-year follow-up after completion of treatment in order to evaluate medium-term effects. A total of 132 patients underwent a follow-up examination 2 years after completion of treatment and were evaluated with an intention-to-treat approach. In the second follow-up year, all treatment groups had lower but not significantly different relapse rates compared to the control group. The most intensive treatment (PMT+CP+KC) produces a clinically relevant reduction in rehospitalization rate (a 26% reduction compared to the control group). In comparison with the non-specifically treated control group, whose original effect decreased, at least a medium-term therapeutic effect was recorded in the treatment groups. In this study we look into the question of whether, in addition to neuroleptic treatment, relapse rates among schizophrenic patients can be reduced by means of a combined psychoeducational and psychotherapeutic intervention strategy for patients and their relatives. In a randomized controlled intervention study in an outpatient routine treatment setting, psychoeducational training for medication management, cognitive therapy and work with relatives' groups were compared with each other and with a control group. The patients continued their standard treatment, including neuroleptic relapse prevention. The study comprised 191 chronic DSM-III-R schizophrenics. Data were collected before and after an 8-month intervention phase and at the 1-year follow-up. The group receiving all three treatments had the lowest relapse rates. Moreover, numerous gains recorded in subjective findings suggest that therapeutic work with schizophrenic patients and their relatives is of clinically significant benefit. Little is known about the medium-term durability of cognitive-behavioural therapy (CBT) in a community sample of people with schizophrenia.
                To investigate whether brief CBT produces clinically important outcomes in relation to recovery, symptom burden and readmission to hospital in people with schizophrenia at 1-year follow-up.
                Participants (336 of 422 randomised at baseline) were followed up at a mean of 388 days (s.d. = 53) by raters masked to treatment allocation (CBT or usual care).
                At 1-year follow-up, participants who received CBT had significantly more insight (P = 0.021) and significantly fewer negative symptoms (P = 0.002). Brief therapy protected against depression with improving insight and against relapse; significantly reduced time spent in hospital for those who did relapse and delayed time to admission. It did not improve psychotic symptoms or occupational recovery, nor have a lasting effect on overall symptoms or depression at follow-up.
                Mental health nurses should be trained in brief CBT for schizophrenia to supplement case management, family interventions and expert therapy for treatment resistance.
Psychoeducation does seem to reduce relapse, readmission and encourage medication compliance, as well as reduce the length of hospital stay in these hospital-based studies of limited quality. The true size of effect is likely to be less than demonstrated in this review - but, nevertheless, some sort of psychoeducation could be clinically effective and potentially cost beneficial. It is not difficult to justify better, more applicable, research in this area aimed at fully investigating the effects of this promising approach.
Note: the 27 new citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.