|Year : 2018 | Volume
| Issue : 1 | Page : 35-41
Impact of psychoeducation program on quality of life of schizophrenic patients and their caregivers
Eman S Soliman1, Rehab S Mahdy2, Heba A Fouad2
1 Psychiatry Department, Zagazig University, Zagazig; Clinical Department, College of Medicine, Princess Nourah Bint Abdelrahman University, Riyadh, Egypt
2 Psychiatry Department, Zagazig University, Zagazig, Egypt
|Date of Submission||28-Sep-2017|
|Date of Acceptance||15-Oct-2017|
|Date of Web Publication||29-Jan-2018|
Eman S Soliman
Psychiatry Department, Faculty of Medicine, Zagazig University
Source of Support: None, Conflict of Interest: None
Background Psychoeducation is an evidence-based therapeutic intervention for patients and their families that provides information and support to better understand and cope with illness.
Aim The aim of this study was to assess the effectiveness of patient and caregiver schizophrenia psychoeducation program and its impact on improvement of psychopathology and quality of life (QoL).
Patients and methods This study was carried out on 116 consented schizophrenic patients and their primary caregivers. Severity of the symptoms was rated using Positive and Negative Syndrome Scale. QoL was measured using World Health Organization Quality of Life Questionnaire-short version (WHOQoL-BREF) scale.
Results There is a statistically significant difference between patients who received psychoeducation and those treated as usual regarding question 1, question 2, domain 1 (physical), domain 2 (psychological), domain 3 (social relation), and domain 4 (environment) measured by WHOQoL scale with higher score in received psychoeducation patients.
Conclusion Psychoeducation should be considered as an important intervention for the management of schizophrenic patients as it improves their QoL and supports the caregiver.
Keywords: caregivers, psychoeducation, quality of life, schizophrenic patients
|How to cite this article:|
Soliman ES, Mahdy RS, Fouad HA. Impact of psychoeducation program on quality of life of schizophrenic patients and their caregivers. Egypt J Psychiatr 2018;39:35-41
|How to cite this URL:|
Soliman ES, Mahdy RS, Fouad HA. Impact of psychoeducation program on quality of life of schizophrenic patients and their caregivers. Egypt J Psychiatr [serial online] 2018 [cited 2018 Feb 17];39:35-41. Available from: http://new.ejpsy.eg.net/text.asp?2018/39/1/35/224008
| Introduction|| |
Schizophrenia is one of the most debilitating psychiatric disorders worldwide (Jablensky, 2000; Messias et al., 2007). Caring for patients with schizophrenia is a significant burden on the families and caregivers (Kitchen et al., 2012). Schizophrenia also affects functioning and health of family caregivers, mainly because the caregivers have assumed functions that were performed in the past by psychiatric institutions (Möller-Leimkühler and Wiesheu, 2012). The impact of caregiving on caregivers’ quality of life (QoL) is substantial, especially when experiencing a significant burden, restricted roles and activities, and increased psychosomatic, anxious, or depressive symptoms (ZamZam et al., 2011). Moreover, caregivers’ negative experience may affect their ability to care for the patients . Research on caregivers’ QoL is thus of importance both for the caregivers themselves and indirectly for patients’ health. Caregivers of individuals with schizophrenia have received significant attention in the past few years. Previous studies mainly documented the association of burden with sociodemographic characteristics, coping and social support of caregivers, and severity of symptoms and disabilities of patients (Möller-Leimkühler and Wiesheu, 2012); more rarely, social, economic, and cultural factors were studied, although there is some evidence that these factors have a potential influence on caregiving consequences.
However, recent advancements in biological treatments reduce the need for long-term hospitalization, but the role of the patients’ families is still dominant in the treatment process.
Family psychoeducation is one of the most effective interventions in the treatment of schizophrenia patients. Various studies have shown that psychoeducation of schizophrenic patients’ families not only enhances the social and global functions of the patients but also improves the QoL for both of them (Sharif et al., 2012). Although the principles of psychoeducation programs that run in mental health centers of different countries are somewhat similar, the contents are markedly different. This can reflect the differences in the needs and attitudes of those receiving the education (Papageorgiou et al., 2011). Furthermore, the cultural and psychosocial status and attitude of the family and the patient toward the disorder could be different in various communities (Caqueo-Urízar et al., 2009). Accordingly, the education program content should be adjusted based on the needs of the population.
Cross-cultural or cross-national comparisons of caregivers would help to understand these factors, but only few studies to date have been performed, in particular in developed countries (Roick et al., 2007). Although psychoeducation has been found to be effective in improving the life functioning of patients with schizophrenia in high-income countries, there have been relatively few studies of schizophrenia psychoeducation adapted for low-income and middle-income countries, particularly in Middle East (Ngoc et al., 2016).
Therefore, this study is aiming to assess the effectiveness of PCSPP and its impact on improvement of psychopathology and QoL.
| Patients and methods|| |
Study design, settings, and duration
This is a cross-sectional interventional study (psychoeducation) carried out on schizophrenia patients and their primary caregivers in Zagazig University Hospitals, Sharkia Governorate, during the period from February 2016 to March 2017.
A total of 116 patients and their primary caregivers were included in a sample with the following criteria: all patients who met Diagnostic and Statistical Manual of Mental Disorders, fifth ed. (DSM5) criteria for schizophrenia, both sexes, age ranging from 18 to 50, and all social and educational classes. Inclusion criteria for the caregivers were as follows: adults aged 20 years or more. They should be the primary caregivers to the patient and able to give informed consent. The following subjects were excluded from the sample study: patients with mental retardation, physical disorders, drug dependence, and comorbid psychiatric disorder; patients who received any psychoeducation program during the previous year; and caregivers with any psychiatric diagnosis, physical disorders, mental retardation, and drug abuse, which might interfere with the care of patients during interviews.
Approval was obtained from the Institutional Review Board Faculty of Medicine, Zagazig University. Written informed consents were obtained from participants after discussing with them the aim of the study. Demographic data and disease characteristics were collected at baseline. The primary outcome of the study was improvement in symptom severity. The diagnosis of schizophrenia was based on the Semi-Structured Clinical Interview (according to DSM5). Severity of the symptoms of schizophrenia was rated using Positive and Negative Syndrome Scale (PANSS) (Kay et al., 1987). QoL of patients and their caregivers was assessed using the World Health Organization Quality of Life Questionnaire-short version (WHOQoL-BREF) (Arabic version) (Whoqol Group, 1998).
- PANSS (for patient only): the PANSS was developed in late 1980s to assess clinical symptoms of schizophrenia (Kayet al., 1987). The PANSS includes 30 items on three subscales: seven items covering positive symptoms (e.g. delusions and hallucinations), seven items covering negative symptoms (e.g. social withdrawal, flat affect, lack of motivation), and 16 items covering general psychopathology (e.g. anxiety, depression). The PANSS requires a clinician rater because considerable clinical judgment is required. The ratings can be completed in 30–45 min. Each symptom is rated on a seven-point Likert scale ranging from 1 (not present) to 7 (extreme). Therefore, the positive and negative subscales each range from 7 to 49, the general psychopathology subscale from 16 to 112, and total score from 30 to 210. The PANSS ratings should be based on all the information relating to a specified period, normally identified as the previous week. There are no specific cutoff scores defined. This scale can reliably be administered regularly to assess symptom improvements or exacerbations. In addition, this scale is useful as a pre- and post-assessment of change within psychosocial interventions such as cognitive behavioral therapy or psychoeducation.
- WHOQoL-BREF (Arabic version): the four domains of the WHOQoL-BREF are physical health, psychological (e.g. self-esteem), social relationships (e.g. social support), and environment (e.g. freedom, physical safety). It also contains two general items that are examined separately: question 1 (G1) asks about an individual’s ‘overall perception of QoL’, and question 2 (G2) asks about an individual’s ‘overall perception of their general health’. Participants rated all items on a five-point Likert scale, where 1 indicates low and negative perceptions and 5 indicates high and positive perceptions and high scores demonstrate good QoL. Raw scores for the domains of WHOQoL-BREF were calculated by adding values of single items and were transformed on the scale ranging from 4 to 25, where 25 is the highest and 4 the lowest HRQoL (World Health Organization, 1996). The questionnaire was translated by Dr Ashraf Eljedi into Arabic language using two independent translations from English to Arabic. It has been shown to have good discriminant validity, concurrent validity, internal consistency, and test–retest reliability, and its psychometric properties have been found to be comparable to those of the full 100-item version (WHOQoL-100) (Orleyet al., 1998).
Patient and caregiver schizophrenia psychoeducation program
Schizophrenia patients and their primary caregivers were divided into two groups: group A received PCSPP, and group B received treatment as usual (TAU). Psychoeducation sessions were conducted by psychiatrists during follow-up sessions on a monthly basis (one sessions/month) for 6 months. The intervention provides information to patients and family members about schizophrenia, and how it affects the persons’ thoughts, emotions, and behavior. A detailed account of symptoms and etiology is provided. The family and patient are educated about the treatment in detail. This component includes information about medication, its side effects, and how these can be dealt with, likely benefits of the medicine, adherence to treatment, the importance of follow-up, and information regarding prognosis.
Based on calculation with 2% margin error, power of study 80% (β=0.2), level of confidence of 95% (α=005), the sample size was 116 patients with their primary caregiver. Convenient nonprobability sample was used.
All data were collected, tabulated, and statistically analyzed using SPSS 20.0 for Windows (SPSS Inc., Chicago, Illinois, USA) and MedCalc 13 for windows (MedCalc Software bvba, Ostend, Belgium). Quantitative data were expressed as the mean±SD and median (range), and qualitative data were expressed as absolute frequencies (number) and relative frequencies (percentage). Continuous data were checked for normality by using the Shapiro–Wilk test. Independent Student’s t-test was used to compare two groups of normally distributed data. Mann–Whitney U-test was used to compare two groups of non-normally distributed data. One-way analysis of variance test was used to compare more than two groups of normally distributed data. Kruskal–Wallis H-test was used to compare more than two groups of non-normally distributed data. Spearman’s rank correlation coefficient was calculated to assess the correlations between PANSS score and WHOQoL. We consider (+) sign as an indication for direct correlation and (−) sign as an indication for inverse correlation; also, we consider values close to 1 as strong correlations and values close to 0 as weak correlations. All tests were two sided. P value less than 0.05 was considered statistically significant, P value of less than 0.001 was considered highly statistically significant, and P value of at least 0.05 was considered nonstatistically significant.
| Results|| |
Most of our patients are male (60%), with a mean age of 35.43±10.50 years. Around half of our sample live in rural areas and are not working. In addition, 45% are single and 41.4% had secondary school education. Most of the primary caregivers are patient’s mother (29.3%) or sister/brother (31%).
There is a statistically significant difference between group A patients who received PCSPP and group B patients who received TAU as regards positive, negative, general psychopathology symptoms, and total scores, with a higher score toward TAU, as presented in [Table 1] and [Table 2]. There is a statistically significant difference between group A and group B regarding question 1, question 2, domain 1 (physical), domain 2 (psychological), domain 3 (social relation), and domain 4 (environment) measured by WHOQoL scale, with a higher score in patients who received PCSPP, which is presented in [Table 3].
|Table 1 Demographic data of the studied schizophrenia patients and caregivers of the studied schizophrenia patients|
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|Table 2 Comparison between groups A and B as regards Positive and Negative Syndrome Scale score|
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|Table 3 Comparison between received and not received psychoeducation as regards World Health Organization Quality of Life Questionnaire-short version of patient|
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There is a statistically significant difference between group A and group B caregivers regarding question 2, domain 1 (physical), domain 2 (psychological), domain 3 (social relation), and domain 4 (environment) measured by WHOQoL scale, with a higher score in caregivers who received PCSPP, as shown in [Table 4].
|Table 4 Comparison between groups A and B as regards World Health Organization Quality of Life Questionnaire-short version of caregiver|
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| Discussion|| |
Schizophrenia is a disabling and severe psychiatric disorder that is a major cause of suffering for patients. Schizophrenia also affects functioning and health of family caregivers, mainly because the caregivers have assumed functions that were performed in the past by psychiatric institutions. Caregivers supply the patient with care and support. The impact of caregiving on caregivers’ QoL is substantial, especially when experiencing a significant burden, restricted roles and activities, and increased psychosomatic, anxious, or depressive symptoms. Moreover, caregivers’ negative experience may affect their ability to care for the patients. Research on caregivers’ QoL is thus of importance both for the caregivers themselves and indirectly for patients’ health (Velligan et al., 2009).
Important challenges for the treatment in patients with schizophrenia include the management of suboptimal controlled symptoms, enabling better daily life functioning and improvement of QoL. Understanding the relationship between the different domains of symptoms with QoL is important because interventions that focus on psychotic symptoms alone may fail to improve QoL to the same level. Affective symptoms, namely depression and social anxiety, self-stigma, and social cognition are major obstacles for QoL improvement during long-term treatment in patients with schizophrenia (Schroeder et al., 2012).
Our study included 116 patients diagnosed with Schizophrenia according to Structured Clinical Interview for DSM5 who were randomly selected from the Outpatient Clinic at Zagazig University Hospitals through 6 months, and their caregivers. The aim of this study was to assess the effectiveness of PCSPP and its impact on improvement of psychopathology and QoL.
In this study, we found that there is a statistically significant difference between patients who received PCSPP and those who received TAU regarding positive, negative, general psychopathology symptoms, and total scores, with a higher score in TAU patients. This means that psychoeducation has an important role in reduction of severity of symptoms owing to increased awareness regarding all stages of the disease and early management. This in agreement with many studies worldwide (Tham et al., 2000; Sharif et al., 2012), which found that psychoeducation increases patients’ knowledge about illness and improves adherence to treatment. Also, it motivates patients to accept a maintenance therapy as recommended by the guidelines in comparison with patients with TAU (Tham et al., 2000).
Moreover, psychoeducation therapy has a positive impact on reducing relapses in schizophrenia. It showed a significant benefit on objective QoL and psychological well-being on a sample of patients (Sauvanaud et al., 2017).
In this study, we found a highly statistically significant difference between patients who received psychoeducation and those who received TAU regarding question 1, question 2, domain 1 (physical), domain 2 (psychological), domain 3 (social relation), and domain 4 (environment) measured by WHOQoL scale, with a higher score in patients who received psychoeducation.
This is in agreement with the study that found that psychoeducation reduces severity of symptoms and thus improves QoL and functioning of the patients (Sharif et al., 2012). In addition, psychoeducation led to a greater improvement in the patient’s global function and QoL (Omranifard et al., 2014).
In a systematic review on 44 clinical trials (including 5142 patients), it was found that psychoeducation improves global and social functioning and QoL of the patients and improves satisfaction with mental health services (Xia et al., 2011). All previous studies mentioned are in line with our results and ensure that psychoeducation has a vital role in the improvement of QoL of schizophrenia patients.
In this study we found that there is statistically significant difference between caregivers who received psychoeducation and those who were treated as usual regarding question 2, domain 1 (physical), domain 2 (psychological), domain 3 (social relation), and domain 4 (environment) measured by WHOQoL scale, with higher score in received caregivers as psychoeducation diminishes number of relapses, need for hospitalization thus diminish the financial burden on caregivers. Improvement in the patient’s clinical status may be related to the family’s awareness of strategies for dealing with daily problematic situations. In addition, these results may be related to family orientation to the patient’s symptoms and behavior, and to their skills of coping with them. Findings of the study made by Borkman (1999) revealed that improvements in patients’ symptoms may have been related to enhance treatment compliance because families were better able to supervise the patient’s use of antipsychotic drug owing to increased family awareness. All previous studies mentioned are in line with our results and ensure that psychoeducation has a vital role in the improvement of severity of symptoms and adaptation with the disease (Borkman, 1999).
The study by Sharif et al. (2012) found improvement in caregiver’s QoL owing to family’s awareness of strategies for dealing with daily problematic situations, family orientation to the patient’s symptoms and behavior, and to their skills of coping with them. The findings of this study are consistent with those of earlier research in other countries, suggesting that participation in an educational and supportive group for caregivers of patients with schizophrenia results in better acceptance of the illness, and enhanced adaptability to their caregiving role (Borkman, 1999).
Moreover, psychoeducation offered to the caregivers along with TAU offered to patients might result in diminished perceptions of burden among caregivers and enhanced improvement in the clinical course of patients (Bulut et al., 2016).
Medvene and Krauss (1989) found that mutual aid groups for caregivers of the mentally ill resulted in increased comfort in talking with other caregivers about their problems in caregiving situations. In addition, several studies have reported that the interactions between caregivers in groups may give rise to emotional support and practical help, which is extended to the postintervention period (Citron et al., 1999).
Family psychoeducational intervention may have a positive effect on family burden by reducing many patient risk factors of burden. The study by McDonell et al. (2003) did not find any beneficial effects of family education, as each psychosocial intervention requires financial resources, time, appropriate facilities, and educated and motivated therapists; all of these may be lacking in different communities. This study is in contrast to ours, as psychoeducation programs are readily available in some university hospitals (McDonell et al., 2003).
The effect of family psychoeducation on the family’s QoL has been investigated in a limited manner by previous studies, and most of them have evaluated the family burden. Some studies reported that family psychoeducation can reduce family/caregiver burden (Magliano et al., 2006; Yamaguchi et al., 2006; Chien and Wong, 2007; Chan et al., 2009; Sharif et al., 2012). In contrast, Chan et al. (2009) reported short-term, but not long-term, benefits of psychoeducation for family burden (González-Blanch et al., 2010). Also, González-Blanch et al. (2010) reported that a brief family psychoeducation is not sufficient to reduce the family burden (Carrà et al., 2007). Some other studies also did not find any beneficial effects of family education (McDonell et al., 2003) or family group treatment on family outcomes. Differences among the mentioned studies could be attributed to differences in the methods of family burden assessment and more importantly to the type of intervention.
Conclusion and recommendation
The present findings show the efficacy of a psychoeducational intervention both in improving the patient’s clinical status and in reducing the family caregiver burden. These results suggest that even a short-term psychoeducational intervention for family members of patients with schizophrenia can improve the outcomes for patients and their families. Therefore, we should give psychoeducation much care as it is as important as treatment. Longer follow-up periods are recommended to determine the long-term effects of family psychoeducational intervention on outcomes for patients and their families.
Author wishes to acknowledge their gratitude to the patients for participation in the study and thank the staff at Zagazig University Hospital, Psychiatry Department for their assistance.
The current study was financially supported by Faculty of Medicine in Zagazig University.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]