Assessing the Evidence Base Series

Consumer and Family Psychoeducation: Assessing the Evidence D. Russell Lyman, Ph.D. Lisa Braude, Ph.D. Preethy George, Ph.D. Richard H. Dougherty, Ph.D. Allen S. Daniels, Ed.D. Sushmita Shoma Ghose, Ph.D. Miriam E. Delphin-Rittmon, Ph.D.

Objective: Psychoeducation provides adult consumers who have serious mental illness or co-occurring substance use disorders with information to support recovery. Some models also provide this service to family members. This review examined the evidence base for psychoeducation models in group and individual formats. Methods: Authors reviewed meta-analyses, research reviews, and individual studies from 1995 through 2012. Databases surveyed were PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, the Educational Resources Information Center, and the Cumulative Index to Nursing and Allied Health Literature. Authors chose from three levels of evidence (high, moderate, and low) on the basis of benchmarks for the number of studies and quality of their methodology. They also described service effectiveness. Results: More than 30 randomized controlled trials (RCTs) of consumer psychoeducation and more than 100 RCTs of family psychoeducation provide a high level of evidence for the effectiveness of each model. Reviews of consumer psychoeducation found that experimental groups had reduced nonadherence (primarily with medication regimens), fewer relapses, and reduced hospitalization rates compared with control groups. Some studies found significant improvements in social and global functioning, consumer satisfaction, and quality of life. Multifamily psychoeducation groups (the focus of numerous studies) were associated with significantly improved problemsolving ability and a reduced burden on families, compared with control groups, among other strong outcome effects. Conclusions: Psychoeducation should be included in covered services. Group and family interventions are especially powerful. Future research should assess psychoeducation models with children and adolescents and with individuals from various racial and ethnic backgrounds. (Psychiatric Services 65:416–428, 2014; doi: 10.1176/appi.ps.201300266) Dr. Lyman, Dr. Braude, and Dr. Dougherty are with DMA Health Strategies, Lexington, Massachusetts (e-mail: [email protected]). Dr. George, Dr. Daniels, and Dr. Ghose are with Westat, Rockville, Maryland. Dr. Delphin-Rittmon is with the Office of Policy, Planning, and Innovation, Substance Abuse and Mental Health Services Administration (SAMHSA), Rockville, Maryland. This article is part of a series of literature reviews that will be published in Psychiatric Services over the next several months. The reviews were commissioned by SAMHSA through a contract with Truven Health Analytics and were conducted by experts in each topic area, who wrote the reviews along with authors from Truven Health Analytics, Westat, DMA Health Strategies, and SAMHSA. Each article in the series was peer reviewed by a special panel of Psychiatric Services reviewers. 416

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sychoeducation for adults with mental and substance use disorders is education to expand consumer and caregiver knowledge about the consumer’s illness and treatments, to empower consumers and their families, and to provide them with tools that support selfdirected care and supportive, adaptive family functioning. Prevention of relapse has been a significant focus of many psychoeducation interventions. Two distinct psychoeducation services have been developed—each with its own body of research. One is psychoeducation for consumers, which can be delivered in individual or group settings. The other is psychoeducation for families and others involved in caregiving. The goals for families are to increase their ability to help the consumer cope with his or her situation, to use information about the illness to support the consumer’s recovery, and, in some cases, to reduce family members’ unhelpful reactivity to the illness. Family psychoeducation may be implemented in groups of multiple families or with single families alone. In both cases, these meetings may occur with or without the person who is receiving treatment, although the latter approach is less common. Most of the literature addresses psychoeducation for people with serious mental disorders, such as schizophrenia or bipolar disorder, and, in some cases, co-occurring mental and substance use disorders. The objectives of this review were to describe psychoeducation services

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for consumers with mental or substance use disorders or with cooccurring mental and substance use disorders delivered to a single consumer, to groups of consumers, to family members and consumers, and to multifamily groups; to rate the level of evidence (that is, methodological quality) of existing studies; and to describe the effectiveness of both services in their individual and group formats. We also reviewed implications for practice and future research. The results will provide behavioral health leaders with an accessible summary of the evidence for a range of consumer and family psychoeducation services. The review will also inform decision makers as they consider psychoeducation as a covered benefit. Consumers and their family members may also find this summary helpful as they select services that are specific to their needs.

Description of the service This article reports the results of a literature review that was undertaken as part of the Assessing the Evidence Base Series (see box on this page). For purposes of this series, the Substance Abuse and Mental Health Services Administration defines consumer psychoeducation as a service designed to help individuals with mental and substance use disorders better manage their own recovery. Table 1 presents the definition of consumer psychoeducation and a description of the service components. Family psychoeducation is described in Table 2. Consumers’ relatives or other significant individuals in their lives are targeted in this service. They receive information about prevention, treatment, and recovery strategies for individuals with mental and substance use disorders. Families are encouraged to guide consumers in making good decisions about their own care, such as taking prescribed medications or maintaining engagement in the services and supports that they need. Family members are enlisted as therapeutic agents who provide emotional support to the consumer; however, psychoeducation can also provide support to family members, improve family dynamics, and reduce family members’ PSYCHIATRIC SERVICES

About the AEB Series The Assessing the Evidence Base (AEB) Series presents literature reviews for 13 commonly used, recovery-focused mental health and substance use services. Authors evaluated research articles and reviews specific to each service that were published from 1995 through 2012 or 2013. Each AEB Series article presents ratings of the strength of the evidence for the service, descriptions of service effectiveness, and recommendations for future implementation and research. The target audience includes state mental health and substance use program directors and their senior staff, Medicaid staff, other purchasers of health care services (for example, managed care organizations and commercial insurance), leaders in community health organizations, providers, consumers and family members, and others interested in the empirical evidence base for these services. The research was sponsored by the Substance Abuse and Mental Health Services Administration to help inform decisions about which services should be covered in public and commercially funded plans. Details about the research methodology and bases for the conclusions are included in the introduction to the AEB Series (17).

stress and burden, especially when they are able to share their experiences in groups with other families (1,2). Psychoeducation approaches also aim to increase acceptance of the illness and reduce stigma (3). These goals usually apply to interventions with multiple families in family psychoeducation and to groups of individuals in consumer psychoeducation. Below, we describe consumer and family psychoeducation in more detail.

Consumer psychoeducation The goals of consumer psychoeducation are summarized in Table 1. The service may include verbal, written, or electronic information that is provided in an individual or group format. Most studies of consumer psychoeducation focus on individuals aged 18 years and older with serious mental illness, especially those with schizophrenia and affective disorders (largely bipolar disorder) that require medication. Many studies of

Table 1

Description of consumer psychoeducation Feature

Description

Service definition

Consumer psychoeducation is a direct service designed to help individuals with mental and substance use disorders manage their own recovery. The service supports development of personal strategies that lead to better understanding of mental and substance use disorders. Individuals then use the acquired information to create personal goals. A combination of motivational, educational, and cognitive-behavioral techniques helps consumers create their own definition of recovery, gain control over their lives, and move forward on their paths to recovery. Educational materials and interventions help consumers learn relapse prevention and recovery strategies, build social support, use medications effectively, cope with stress, and manage their symptoms. Provide information to help the consumer invest in the treatment and make optimal decisions about his or her own care, thus reducing the likelihood of relapse or rehospitalization Adults with mental disorders, substance use disorders, or co-occurring mental and substance use disorders Hospital inpatient and day treatment facilities, outpatient facilities, and consumer and family homes

Service goal

Populations Settings for service delivery

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Table 2

Description of family psychoeducation Feature

Description

Service definition

Family psychoeducation is a direct service that provides the relatives of adults and children who have (or are at risk of having) mental and substance use disorders with information about prevention, treatment, and recovery strategies for that disorder. The service aims to increase the family’s awareness about related risk factors, symptoms, treatment options, and other resources. The family is encouraged to guide the consumer in making good decisions about his or her own care, such as taking prescribed medications or maintaining engagement in needed services and supports. Provide families or caregivers of consumers with information about the illness that can help families give appropriate supports for consumer recovery Adults with mental or substance use disorders or co-occurring mental and substance use disorders. Family psychoeducation is also conducted with families of children and adolescents (not reviewed here). Hospital inpatient and day treatment facilities, outpatient facilities, consumer and family homes

Service goal Populations

Settings for service delivery

psychoeducation—for example, the study by Dixon and colleagues (4)— have indicated that substance use is a common problem among individuals with mental disorders, and some psychoeducation studies have included people with comorbid mental and substance use disorders. However, we did not find any reviews of psychoeducation for consumers who had a sole diagnosis of a substance use disorder. There is no single accepted model of service for consumer psychoeducation. Psychoeducation as an adjunct to pharmacotherapy is a common focus. In such programs, various methods and media are used to provide information about medication, with the goal of improving adherence to medication regimens and awareness of side effects. Information about the illness (for example, warning signs of relapse) and various treatments is also provided. Traditionally, consumer psychoeducation has been delivered by trained mental health professionals, such as psychiatric nurses, social workers, psychologists, or psychiatrists. The duration of the service in consumer psychoeducation models ranges from several sessions to a year or more (2,4,5). Family psychoeducation The goals of family psychoeducation are summarized in Table 2. Most of the research on family psychoeducation has been with adults who have 418

schizophrenia or schizoaffective disorder. However, in recent years there has been a growing focus on bipolar disorder. Some studies have included people with major depression, obsessive-compulsive disorder, anorexia nervosa, and borderline personality disorder (6). Family psychoeducation is frequently offered within the context of other family-based services (for example, counseling and support). A number of models include cognitive-behavioral components (7), particularly in the treatment of affective disorders. Family psychoeducation originated more than 30 years ago, as schizophrenia research evidenced an emerging awareness that traditional family therapy approaches tended to focus on family dysfunction (a deficit model, as the name implies) rather than on the natural confusion among consumers and their families about how to deal with serious mental illnesses (2). It was hypothesized that both populations needed accurate information about the illness and associated interventions in order to deal with the illness effectively. Families with high emotional reactivity to the illness and its consequences (for example, families exhibiting negative, critical responses) were seen as particularly appropriate for this type of approach. It was also recognized that families needed to share their experiences and develop PSYCHIATRIC SERVICES

adaptive strategies with other families and that they could benefit from developing a network of peer support if the psychoeducation intervention was of significant duration—usually several years (2). Generally, family psychoeducation services last from nine months to five years, are diagnosis-specific, and focus largely on consumer outcomes, with some attention paid to the well-being of the family (6). A range of family psychoeducation models has been developed, with variations in session length, duration, and format. Some models with as few as two sessions have been recommended for situations in which longer-term support is not possible. The specific content of each session varies according to the needs of its members. Family psychoeducation models have been designed for multifamily groups, single families, or a mix of family and individual sessions. These models typically are delivered by trained mental health professionals. However, they may be delivered by trained peers, as in the peer-led multifamily groups in Familyto-Family psychoeducation (8) (a model not reviewed here). In addition, there is variation in service delivery settings and in the degree of emphasis on didactic, cognitive-behavioral, and systemic techniques (6). Psychoeducational multifamily group intervention was initially developed as a psychosocial treatment for people who were hospitalized for psychiatric treatment (2). It is now recognized in the National Registry of EvidenceBased Programs and Practices (9). A tenet of this work is that family discouragement, overinvolvement, or high levels of expression of critical emotions can often contribute to relapse. In this approach, practitioners invite up to six consumers and their families to meet in biweekly psychoeducation groups for six months (9) to several years (2). Treatment covers three phases. In the first phase, practitioners meet with single families to focus on social and vocational rehabilitation and prevention of relapse. The second phase uses problem solving in multifamily groups to address community functioning, and the third phase is devoted to developing a social network within the group for ongoing support

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and monitoring. The goals are to provide information on mental illness, develop coping and problem-solving skills, create social supports, and develop alliances among consumers, families, and professionals. This model has been adapted for adults with depression, borderline personality disorder, affective disorders, and Alzheimer’s disease and for children with a diagnosis of conduct disorder. Family behavioral management deserves mention as an early approach to family psychoeducation that led to the development of more recent models. It has been described by McFarlane and colleagues (2) as the most behavioral among psychoeducation interventions, and these authors have applied many of its principles in their multifamily group psychoeducation model. Family behavioral management was developed at the University of Southern California by Falloon and colleagues (10,11) and Liberman and colleagues (12) for people with schizophrenia. It has been adopted by the U.S. Department of Veterans Affairs and implemented in many parts of Europe. Its problemsolving approach has been cited in numerous meta-analyses, for example by McFarlane and colleagues (2), Murray-Swank and Dixon (13), and Pitschel-Walz and colleagues (14), although most studies cited in these reviews were conducted prior to 1995. A primary assumption is that the family is doing its best, given the circumstances of having a family member with mental illness. The intervention begins with assessment and proceeds sequentially through treatment and ongoing review. Clinicians conduct a behavioral assessment of the needs and strengths of each person in the family as well as the whole family unit. This is followed by family sessions in the home that focus on psychoeducation, communication, and development and rehearsal of improved problem-solving strategies. Family behavioral management goes beyond pure psychoeducation and includes skill-building strategies. However, we note this early approach (rather than conduct an in-depth review) because of its seminal contribution to the development of contemporary family psychoeducation models. PSYCHIATRIC SERVICES

The various models of consumer psychoeducation (for example, with a consumer alone, in consumer groups, in family meetings with or without the consumer, or in multifamily groups) may leave decision makers with questions regarding which model or models to support. Consumers and their families must choose a model that best meets their capabilities and needs. This review of the different models and their outcomes aims to provide information to inform these and other decisions.

Methods Search strategy We reviewed meta-analyses, research reviews, and individual studies from 1995 through 2012. One review that was published in 2013 is also included because of its timely relevance. We surveyed major databases: PubMed (U.S. National Library of Medicine and National Institutes of Health), PsycINFO (American Psychological Association), Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, the Educational Resources Information Center, and the Cumulative Index to Nursing and Allied Health Literature. Bibliographies of major reviews and metaanalyses were also examined. We used combinations of the following search terms: psychoeducation, consumer education, consumer psychoeducation, brief consumer education, family psychoeducation, consumer/family psychoeducation, brief family education, family behavioral (or behavior) management, behavioral family management, adjunctive family psychoeducation, mental illness, mental health education, medication management, addict, substance abuse, mental, and behavioral. We also searched for the following interventions: psychoeducational multifamily group, Family-to-Family psychoeducation, and Clinician-Based Cognitive Psychoeducational Intervention for Families. Inclusion and exclusion criteria This review was limited to U.S. and international studies in English and included the following types of articles:

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randomized controlled trials (RCTs), quasi-experimental studies, singlegroup time-series design studies, review articles (meta-analyses and systematic reviews), and studies of psychoeducation services for adults and their families or caregivers. Excluded were studies of psychoeducation for people with brain injury or other serious cognitive deficits, such as pervasive developmental disorders or very low intelligence. Also excluded were studies that focused primarily on outcomes for family members, such as Family-to-Family approaches, rather than on outcomes for the individual with the identified illness. Some models that have been framed as psychoeducation in the literature (2) have included treatment interventions aimed at changing family dynamics. These interventions were considered to be a form of family therapy (as opposed to family psychoeducation only). Therefore, they were not included in this review. Functional Family Therapy (3,15) is an example of a family treatment that was excluded. There is some overlap in the educational components of psychoeducation and skill building, and these two services can easily be confused or placed in the same category. Skillbuilding approaches, some of which include psychoeducation, are reviewed in a separate article in this series (16) and are not covered here. Finally, although we note the relevance of psychoeducation approaches for families of children and adolescents, we did not include this literature. There is little psychoeducation research involving younger populations, and the intervention approaches and treatment contexts for these age groups are different from those for adults; therefore, we focused on adult psychoeducation models. Strength of the evidence The methodology used to rate the strength of the evidence is described in detail in the introduction to this series (17). The abstract and research designs of the identified studies were examined. Three levels of evidence (high, moderate, and low) were used to indicate the overall research quality of the collection of studies. Ratings 419

were based on predefined benchmarks that took into account the number of studies and their methodological quality. In rare instances when the ratings were dissimilar, a consensus opinion was reached. In general, high ratings indicate confidence in the reported outcomes and are based on three or more RCTs with adequate designs or two RCTs plus two quasi-experimental studies with adequate designs. Moderate ratings indicate that there is some adequate research to judge the service, although it is possible that future research could influence reported results. Moderate ratings are based on the following three options: two or more quasi-experimental studies with adequate design; one quasiexperimental study plus one RCT with adequate design; or at least two RCTs with some methodological weaknesses or at least three quasiexperimental studies with some methodological weaknesses. Low ratings indicate that research for this service is not adequate to draw evidencebased conclusions. Low ratings indicate that studies have nonexperimental designs, there are no RCTs, or there is no more than one adequately designed quasi-experimental study. We accounted for other design factors that could increase or decrease the evidence rating, such as how the service, populations, and interventions were defined; use of statistical methods to account for baseline differences between experimental and comparison groups; identification of moderating or confounding variables with appropriate statistical controls; examination of attrition and follow-up; use of psychometrically sound measures; and indications of potential research bias. Effectiveness of the service We also described the effectiveness of the service—that is, how well the outcomes of the studies met the service goals. We compiled the findings for separate outcome measures and study populations, summarized the results, and noted differences across investigations. We considered the quality of the research design in our conclusions about the strength of 420

the evidence and the effectiveness of the service.

Results and discussion Level of evidence Although the search revealed a number of reviews of family psychoeducation alone, some reviews of consumer psychoeducation included various versions of both approaches under the rubric of “psychoeducation” or “psychosocial interventions.” This made it difficult to isolate the effects of consumer psychoeducation. Nonetheless, we separately rated the level of evidence for consumer psychoeducation and for family psychoeducation, either of which can be delivered individually or in groups. Table 3 summarizes reviews of consumer education alone, family education alone, and consumer and family education together. Table 4 summarizes recent RCTs of consumer and family psychoeducation that were not included in previous reviews. Consumer psychoeducation. The level of evidence for consumer psychoeducation is high, although not as strong as the evidence for family psychoeducation. This rating is based on three reviews of 32 RCTs of consumer psychoeducation alone (5,18,19) plus two RCTs that were published more recently (20,21). (Some RCTs were evaluated in multiple reviews.) The focus of each review was sufficiently different from most of the others to make it challenging to assess the evidence base for psychoeducation as a stand-alone service. For example, one review targeted psychoeducation in support of medication adherence only (5), and two reviews provided an overview of various psychosocial interventions for bipolar disorder (18,19). One, a Cochrane review, covered psychoeducation as an addition to standard treatment for schizophrenia but merged various forms of psychoeducation (22). Limitations in research on this topic covered in the reviews included the heterogeneity of the services examined and the methods used to study them. For example, a 2006 review of 21 RCTs of the effects of educational interventions for users of mental health services who were receiving psychotropic PSYCHIATRIC SERVICES

medication found that results could not be pooled because there was so much variability in the measurement of outcomes (5). We noted a 2013 review by Addington and other experts (23) in which the level of evidence was rated as moderate on the basis of a Delphi model of the consensus of experts. However, more recent studies with improved methods have assessed functioning, quality of life, adherence to treatment, hospitalization rates, and client satisfaction (18,20,22). For example, a 2011 Cochrane review of psychoeducation as an addition to standard treatment cited 44 RCTs involving more than 5,000 participants (22). Thus the level of evidence in support of consumer education can be described as high, with the caveats noted here. Family psychoeducation. The level of evidence for psychoeducation for family members of consumers with schizophrenia or other psychotic disorders is even higher than the level of evidence for consumer education. We found eight reviews of family psychoeducation alone that analyzed more than 100 RCTs (1,2,13,14,24–27) and five reviews in which consumer and family psychoeducation were summarized together (3,7,23,28,29) (Table 3). (Some RCTs were evaluated in multiple reviews.) In addition, we found two recently published RCTs that were not included in other reviews (30,31) (Table 4). Addington and colleagues (23) rated the evidence level for psychoeducation for families coping with first-episode psychosis as strong in single-family interventions and in multifamily groups. As noted in a review by McFarlane and colleagues (2), as of 2003 numerous reviews (at least eight systematic reviews in the past decade; the number of studies covered in these reviews was not reported) had found significant effects for family psychoeducation for schizophrenia (1,6,14,32– 38). One meta-analysis of 25 studies (mainly RCTs) that was published in 2001 found a high level of evidence supporting the positive effects of family psychoeducation on relapse and rehospitalization rates (14). However, this study merged various family psychoeducation models, thus affecting the level of evidence for any

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Table 3

Review articles of consumer and family psychoeducation included in the reviewa Service type and study

Focus of review

Studies reviewedb

Outcomes measured

Educational interventions related to psychotropic medications for consumers with a mental disorder

21 RCTs: 10 for patients with schizophrenia, 11 for patients with various mental disorders

Knowledge retention, medication and treatment adherence, relapse, insight into illness

Beynon et al., 2008 (19)

Psychosocial interventions for consumers with bipolar disorder

3 RCTs for individuals with type I (manic episodes) or type II (depressive episodes with hypomania) bipolar disorder or with both types

Xia et al., 2011 (22)

Psychoeducational interventions compared with standard modes of knowledge provision for people with schizophrenia

44 studies, mostly of inpatients

Overall relapses, manic and depressive relapses, adverse events leading to discontinuation, other treatmentrelated adverse events, suicide or suicide attempts Medication adherence, relapse, readmission, length of hospital stay, social and global functioning, satisfaction with treatment

Lolich et al., 2012 (18)

Psychosocial interventions for consumers with bipolar disorder

8 RCTs of consumer and family psychoeducation, 11 RCTs of family therapy interventions

Clinical symptoms, hospitalization, medication adherence, time to relapse, duration of illness

Psychopharmacologic and psychosocial treatments for consumers with schizophrenia

Relapse

Relapse

Consumer Fernandez et al., 2006 (5)

Family Lehman and Steinwachs, 1998 (26)

Dixon et al., 2000 (1)

Family psychoeducation for consumers with schizophrenia

Schizophrenia Patient Outcomes Research Team (PORT) review of family psychosocial interventions 16 RCTs or other rigorous evaluations

Pitschel-Walz et al., 2001 (14)

Family interventions for consumers with schizophrenia

25 intervention studies of “sufficient” quality

Relapse, clinical symptoms, functional status, mental status, treatment adherence, disruptive behavior, hospitalization, cost

Summary of findings Patients who received the educational intervention demonstrated increased knowledge, but no difference was found in adherence or incidence of relapse. Consumers provided with multiple education sessions had greater knowledge gains in the short term (up to 1 month); however, the effectiveness of multiple sessions in the long term (2 years) was inconclusive. Group psychoeducation was significantly associated with fewer relapses overall and with fewer manic and depressive relapses. Compared with usual care, individual psychoeducation was related to fewer manic episodes, but no group differences were found in prevention of overall relapses or depressive relapses. Psychoeducation was related to lower incidence of nonadherence in the short, medium, and long terms; lower rates of relapse and readmission; better social and global functioning; greater clinical improvement; greater satisfaction with mental health services; and improved quality of life. Psychoeducation was associated with fewer euphoric, mixed, and depressive episodes; fewer days of hospitalization; fewer recurrences; more time to relapse; and better medication adherence. In combination with pharmacotherapy, family interventions that provided some combination of illness education, support, problem-solving training, or crisis intervention reduced 1-year relapse rates. Family psychoeducation was related to improvements in all outcomes. Optimal intervention length and effectiveness may depend on program goals, phase of illness, family and patient life cycle stages, and cultural background. Most interventions did not resemble usual practice, but several studies in clinical environments that were more representative of usual care had positive findings. Inclusion of relatives in treatment was related to reduced relapse rates. This effect was stronger when family interventions continued for longer than 3 months. Continues on next page

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Table 3 Continued from previous page

Service type and study

Focus of review

Studies reviewedb

Outcomes measured

McFarlane et al., 2003 (2)

Family psychoeducation for consumers with schizophrenia

MurraySwank and Dixon, 2004 (13)

Family psychoeducation for consumers with schizophrenia and with bipolar disorder

.30 RCTs, including 11 studies of “relapse in major outcome trials of family psychoeducation” 30 RCTs

Relapse, patient recovery, family well-being, participation in vocational rehabilitation, costs Relapse, clinical symptoms, hospitalization

Kreyenbuhl et al., 2010 (27)

Psychopharmacologic and psychosocial treatments for consumers with schizophrenia

Schizophrenia PORT review, number of studies not specified

Relapse, hospitalization, medication adherence, clinical symptoms, stress

Justo et al., 2007 (25)

Family psychosocial interventions for consumers with bipolar disorder

7 RCTs

Clinical symptoms, relapse

Lincoln et al., 2007 (24)

Psychoeducation for consumers with schizophrenia and other psychotic disorders

18 RCTs

Relapse, clinical symptoms, knowledge, medication adherence, functioning

Psychosocial interventions for consumers with bipolar disorder

General review, number of RCTs not specified

Relapse, medication adherence, clinical symptoms, hospitalization, social and vocational functioning

Psychosocial interventions for consumers with bipolar disorder

Not specified

Relapse, clinical symptoms, hospitalization, medication adherence, social functioning

Consumer and family Zaretsky, 2003 (3)

Miklowitz, 2006 (28)

Summary of findings Compared with standard care or medication alone, family psychoeducation was highly effective; it was reliably associated with decreased relapse and hospitalization rates. Family psychoeducation was highly effective in reducing relapse rates among consumers with schizophrenia and schizoaffective disorder. Family psychoeducation was also effective in the treatment of bipolar disorder. Interventions for families of individuals with schizophrenia reliably reduced rates of relapse and rehospitalization and (less consistently) increased medication adherence, reduced psychiatric symptoms, and reduced levels of perceived stress for patients. Key elements of effective family interventions included illness education, crisis intervention, emotional support, and training in how to cope with illness symptoms and related problems. Meta-analyses could not be conducted because of inconsistency in interventions and outcomes across studies. For studies examining family interventions, there were inconsistent effects or no added effects with the family intervention. Psychoeducation was reliably associated with reduced relapse and increased knowledge, but it was not related to symptoms, functioning, or medication adherence. Compared with psychoeducation for consumers alone, interventions that included families were more effective in reducing symptoms by the end of treatment and in preventing relapse at follow-up. Consumer psychoeducation was related to better medication adherence, fewer hospitalizations, delayed time to mania, and improved social and vocational functioning. Family educational interventions were related to lower relapse rates and increased time to relapse and to decreased depressive symptoms. Family involvement in treatment provided benefits over a similarly intensive individual therapy (for example, fewer hospitalizations and relapses and better medication adherence). Consumer psychoeducation (individual and group) was effective in lessening symptoms of mania (but not of depression) and in reducing relapses. Continues on next page

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Table 3 Continued from previous page

Service type and study

a b

Focus of review

Studies reviewedb

Outcomes measured

Miklowitz and Scott, 2009 (7)

Adjunctive psychotherapy for consumers with bipolar disorder

19 RCTs of individual family and group therapies

Relapse, time to recovery, symptom severity, medication adherence, psychosocial functioning, hospitalization

Välimäki et al., 2012 (29)

Psychoeducational interventions using information and communication technology for consumers with schizophrenia or related psychosis

6 studies

Addington et al., 2013 (23)

Evidence-based components of services for consumers with a first episode of psychosis

280 peer-reviewed articles; number of studies of consumer and family psychoeducation not specified

Patient treatment adherence, global state, mental state, level of knowledge and insight, behavior, quality of life, satisfaction with treatment, health and social needs, service utilization, health economic outcomes, death Not identified

Summary of findings Consumer psychoeducation was related to fewer relapses, greater medication adherence, improved symptoms and functioning, less time in the hospital, higher levels of social and work functioning, greater likelihood of attending outpatient appointments, and lower likelihood of emergency consultation (group psychoeducation). There was no effect on depressive relapse. Psychoeducation using information and communication technology as a supplement to standard care did not improve general mental state, negative or positive symptoms, global state, level of knowledge, or quality of life. However, findings regarding level of knowledge and satisfaction with treatment were inconsistent. The authors concluded that this approach has potential.

Using the Delphi technique, reviewers rated the evidence for the effectiveness of multifamily group psychoeducation as strong and evidence for individual consumer psychoeducation as moderate.

Reviews are listed in chronological order under each type of service. Not all of the publications were comprehensive reviews; thus not all reported numbers of studies reviewed or the sample sizes of those studies. Reviews of “psychosocial interventions” included various types of psychosocial interventions, one of which was psychoeducation. Some reviews covered both consumer and family psychoeducation.

specific model. A comprehensive review in 2004 by Murray-Swank and Dixon (13) cited more than 30 RCTs supporting the effectiveness of family psychoeducation compared with control groups. In 2007, Lincoln and colleagues (24) conducted a metaanalysis of 18 RCTs (selected from 199 abstracts) that examined the effects of consumer-only versus family psychoeducation in the treatment of schizophrenia and other psychotic disorders, which also supported a high level of evidence. The evidence in support of this approach with individuals who have bipolar disorder is growing (18,28), but evidence is less extensive for families of adults with other disorders. Indeed, Zaretsky (3) noted that research on the use of this approach for individuals with bipolar disorder lags PSYCHIATRIC SERVICES

about a decade behind schizophrenia research. A systematic review of seven RCTs and a number of quasiexperimental studies assessing family psychoeducation for individuals with bipolar disorder noted that the evidence was insufficient to draw conclusions that could be generalized to everyday practice (25). In contrast, a subsequent review of controlled trials examining treatments for bipolar disorder concluded that there was sufficient evidence for various family interventions, including psychoeducation, as adjuncts to pharmacotherapy (19). As recently as 2011, an RCT of family psychoeducation for people with major depression was conducted by Shimazu and colleagues (30), which suggests that the evidence base in this diagnostic area continues to grow.

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Effectiveness of the service A recent review of psychoeducation for people with schizophrenia stated that “there is a medium effect size for psychoeducation for relapse and rehospitalization if both the family and the patient participate” (39). However, this was a general review that combined psychoeducation approaches, and in the case of family psychoeducation, it does not shed light on possible differences in effects between working with families singly versus in multifamily groups. Therefore, as in our ratings of levels of evidence, we attempted to discriminate between psychoeducation models, and we summarize their effects to the extent allowed by existing literature. Consumer psychoeducation. A Cochrane review including more than 423

Table 4

Randomized controlled trials of consumer and family psychoeducation included in the review Service type and study Consumer Chien et al., 2012 (21)

Rabovsky et al., 2012 (20)

Family Shimazu et al., 2011 (30)

Kopelowicz et al., 2012 (31)

Comparison group

Outcomes measured

Usual care plus 6-session, nurse-led psychoeducation program (N=39)

Usual care (N=40)

Individuals in inpatient treatment, mixed diagnosis (N=82)

Psychoeducation for a group with mixed diagnoses (N=43)

Nonspecific intervention control (N=44)

Mental state, insights into illness and treatment, self-efficacy in managing difficult life situations, overall health Readmission, treatment adherence, clinical variables (e.g., global functioning)

Consumers with major depression and their primary family members (N=57) MexicanAmerican adults with schizophrenia spectrum disorder and their key relatives (N=174)

Usual care for patients plus family psychoeducation without patients (N=25) Adapted (N=64) or standard (N=53) multifamily group therapy

Usual care (N=32)

Population

Intervention

Individuals in outpatient treatment for first-onset mental illness (N=79)

5,100 participants with schizophrenia (mostly in hospital settings) from 44 trials conducted between 1988 and 2009 found that there were fewer incidents of nonadherence and relapse in groups that were receiving consumer psychoeducation than in groups that were not, both for the medium and long term (22). The authors concluded that consumer psychoeducation promotes better social and global functioning, improves satisfaction with mental health services, and supports quality of life. However, this review merged individual and group consumer education models; thus it does not provide evidence regarding whether one approach is more effective. We were unable to find other reviews that examined the effects of psychoeducation alone with individual consumers compared with standard care (that is, usual therapies not involving psychoeducation). A review by Zaretsky and colleagues (40) found 424

Usual care (N=57)

Summary of findings

Depressive symptoms, levels of expressed emotion of family members Medication adherence, hospitalization

that consumer psychoeducation as an adjunct to pharmacotherapy was related to better medication adherence, fewer hospitalizations, delayed time to mania, and improved social and vocational functioning, compared with pharmacotherapy without consumer education. A 2007 review by Lincoln and colleagues (24) involving people with schizophrenia and other psychotic disorders compared individual and family psychoeducation models. They found that psychoeducation interventions that included families were more effective than psychoeducation with consumers alone in reducing symptoms and preventing relapse in the one-year follow-up and that pre-post effects were not significant for the comparison group of consumers who participated alone in psychoeducation. We also found a review of the use of information technology (that is, electronic media, such as video and audio recordings; television, radio, and PSYCHIATRIC SERVICES

Compared with the control group, 2 weeks after intervention the psychoeducation group had greater improvements in mental and overall health status, perceived selfefficacy, insights into their treatment and illness, and hospitalization duration. Psychoeducation was associated with better treatment adherence after 3 months and a lower suicide rate. For most other outcomes, there were no differences between psychoeducation and control groups. Patients who received psychoeducation had significantly longer times to relapse and lower rates of relapse at 9-month follow-up than those in the control group. A multifamily group intervention adapted specifically to improve medication adherence for a specific group of consumers was more effective (resulted in higher adherence) than standard multifamily group therapy or usual care.

telephonic communications; and computers) in consumer psychoeducation for people with schizophrenia (29). The authors examined six studies with a total of 1,063 participants. They did not find any significant improvements over standard care (usual treatment without technology-enhanced psychoeducation) in the primary outcomes of participant adherence and global state. However, people in the experimental group perceived that they received more social support than did those in the standard care group, and their mental state improved in the short term. When technologymediated psychoeducation was added to standard care and compared with standard care alone, adherence to medication was significantly improved in the long term, but general adherence to treatment was not improved in the short term. In addition, general mental and global states, symptoms, level of knowledge, and quality of life did not improve relative to the control

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group. The authors concluded that they found “no clear benefit” from using information technologies in consumer psychoeducation to improve various outcomes, although their findings regarding long-term adherence were encouraging. However, the authors noted that education and support that used technology showed great promise and that further research is warranted. Group psychoeducation for people with bipolar disorder has been a growing focus of research in the past decade. In a 2006 review of psychosocial interventions for the treatment of bipolar disorder, Miklowitz (28) cited three RCTs (41–43) that found significant results for group psychoeducation models. Together, these studies indicated that both shortterm interventions (seven to 12 sessions) and longer-term interventions (21 sessions in combination with pharmacotherapy) reduced manic relapses and increased time between them and also improved social functioning relative to control groups receiving pharmacotherapy without psychoeducation. These studies did not find significant reduction of depressive symptoms in bipolar cycles (41–43). One review of 45 articles published between 2000 and 2012 examined a variety of interventions under the broad category of “psychosocial” (18). The authors reviewed cognitivebehavioral, psychoeducational consumer groups and “systematic care” models (that is, combined psychosocial interventions with an emphasis on psychoeducation and ongoing communication with a team of professionals supporting connection with medical services, in particular) as well as interpersonal and family therapy interventions. They found that this range of interventions contributed to significant improvements in therapeutic adherence and in consumer functioning. However, because the authors combined the results from these models in their evaluation, it is difficult to isolate the effects of consumer psychoeducation in this review. A subsequent RCT, published in 2012, examined group psychoeducation for people hospitalized with various serious psychiatric disorders (20). The authors found that the PSYCHIATRIC SERVICES

experimental group had higher levels of treatment adherence and a lower suicide rate at the three-month follow-up compared with a “nonspecific” intervention control group, but they found no other significant differences between groups for most other outcome variables. Family psychoeducation. As early as the 1998 Patient Outcomes Research Team (PORT) study, family psychoeducation was recommended as one component in the treatment of adult schizophrenia (26). In the 2009 follow-up PORT study, one recommendation was to offer family-based services to individuals with schizophrenia who have ongoing contact with their families (27). The authors identified the key elements of effective family interventions as “illness education, crisis intervention, emotional support, and training in how to cope with illness symptoms and related problems.” A more recent RCT compared the effectiveness of two approaches— routine outpatient care without psychoeducation and a six-session, nurse-led, psychoeducation program in conjunction with routine outpatient care—for Chinese patients with mental health problems who were newly referred to an outpatient clinic in Hong Kong (21). Compared with patients receiving routine outpatient care only, the psychoeducation group had significantly greater improvements in mental and overall health status, insights into their treatment and illness, and hospitalization rates at the six-month follow-up assessment. This suggests that brief family psychoeducation models in conjunction with standard treatment may be effective, at least in some cases. In their 2003 review, McFarlane and colleagues (2) noted that when families in treatment participated in psychoeducation, the average relapse rate among individuals with schizophrenia was 15% per year, compared with 30%240% in comparison groups receiving only individual therapy with medication or medication alone. The authors noted that only three studies out of nearly 30 reviewed found no effect for family psychoeducation. There is a body of research suggesting that the multifamily group model may be more effective than

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psychoeducation for single families. Two RCTs by McFarlane and colleagues (44,45) comparing these models found significantly lower relapse rates in the multifamily group. Shimazu and colleagues (30) examined family psychoeducation for people who were in maintenance treatment for depression. They found that time to relapse was significantly longer in the psychoeducation group than in the control group (no psychoeducation). The relapse rates at the nine-month follow-up were 8% in the experimental group and 50% in the control group. The researchers concluded that family psychoeducation is effective in the prevention of relapse among adult patients with major depression. In their review of psychosocial treatments for bipolar disorder, Miklowitz and Scott (7) noted that “to be effective, adjunctive psychosocial treatments must go beyond simply educating patients about the illness and the pharmacological strategies to avoid relapse.” They also described a 2009 study of hospitalization rates by Scott and colleagues (46) suggesting that structured psychoeducation approaches can produce significant cost savings by reducing inpatient days. Our review suggests that including families in psychoeducational interventions is likely to be more effective than providing psychoeducation to consumers alone, depending on the willingness and ability of the consumers and their family members to participate. A number of authors, including Dixon and colleagues (1) and McFarlane and coauthors (2), have noted that involving families in consumer education services occurs far less often than it should. Some families are difficult to engage, some consumers resist the involvement of family members, and, in the case of multifamily groups, the logistics of involving multiple families at the same time and over a long period can be challenging. However, research underscores the power of bringing families together to support each other and share their experiences and knowledge. The group format of this approach can reduce stigma and create a network of family peer support that can sustain adaptive functioning and prevention of 425

Evidence for the effectiveness of consumer psychoeducation for adults: high Compared with control conditions, consumer psychoeducation demonstrates consistent evidence for the following outcomes: • Improved functioning • Improved insight • Reduced incidence of nonadherence • Improved quality of life • Higher satisfaction with services

relapse beyond the termination of treatment. Duration of treatment. In their PORT study, Kreyenbuhl and colleagues (27) concluded that the evidence supported psychoeducational interventions of at least six months. If this is not feasible, the authors recommended that the intervention should last a minimum of four sessions (as noted above, others have recommended as few as two sessions under certain circumstances). Kreyenbuhl and coauthors recommended treatment that includes education, training, and support for people with schizophrenia. However, McFarlane and colleagues (2) described a study by Cuijpers (47) that concluded that interventions of less than ten sessions had no significant effects on family burden. Similarly, Pitschel-Walz and colleagues (14) found that family psychoeducational interventions were most effective when they were of at least three months’ duration. Moreover, McFarlane and coauthors (2) advised that for families, the long-term symptoms and burdens of schizophrenia are likely to erode any short-term positive effects of family psychoeducation models.

These authors concluded that the significant difference in relapse rates between people in family psychoeducation services and those in nonpsychoeducation control groups increases with time in treatment, such that relapse rates after two years in treatment are well below 50% of the rates for control participants. Special populations. Most reviews did not address differential effects of consumer and family psychoeducation across subpopulations and, in fact, did not report any ethnic, racial, or linguistic characteristics. However, on the basis of a single study, McFarlane and colleagues (2) suggested that psychoeducation for an individual family may be more effective than psychoeducation for multifamily groups among African-American families with low expressed emotion (that is, low negative emotional reactivity to the illness). The authors also noted that studies in China found positive effects that were comparable to those found in studies with EuropeanAmerican populations. Nearly a decade later, Chien and colleagues (21) found similarly positive results in current work with participants from Hong Kong, as described above.

Evidence for the effectiveness of family psychoeducation for adults: high Compared with control conditions, family psychoeducation for adult consumers with schizophrenia or other psychotic disordersa demonstrates consistent evidence for the following outcomes: • Decreased relapse and rehospitalization rates • Reduced burden on families • Greater knowledge of the disorder and the mental health care system • Improved ability to solve problems • Better self-care •Improved quality of life a

Research is less extensive for families of adults with other disorders.

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In 1995, Telles and colleagues (48) conducted a small (N=42) cross-cultural study with first-generation, Spanishspeaking individuals with schizophrenia who were immigrants to the United States. As reported in a meta-analysis by Pitschel-Walz and colleagues (14), there was a small effect size for improved outcomes in favor of the control group, which received individual psychotherapy with case management. However, participants in the experimental group (who received behavioral family intervention) who were the least acculturated had the most negative outcomes. Hence, the authors suggested that levels of acculturation might have moderated treatment effects. Kopelowicz and colleagues (31) conducted an RCT of multifamily groups involving Mexican Americans with schizophrenia in which the usual multifamily group model was compared with an adaptation of that model. The adaptation focused specifically on medication adherence and sought to address beliefs and attitudes of the subgroup of Mexican-American people living in that particular local culture, such as social norms and perceived lack of resources. For example, the leaders corrected the misconception of family members that they and the consumer were not eligible for medication reimbursement. The authors found significantly higher medication adherence, lower likelihood of hospitalization, and longer time to hospitalization among those in the adapted group model compared with those in the standard multifamily group. The results of this study suggest that assessing the beliefs, attitudes, and social norms of the target population and adapting family psychoeducation models accordingly may help to improve outcomes for various populations. In fact, these adaptations would seem to be essential given the varying cultural beliefs about mental illness. This type of cross-cultural research is likely to be especially important for underserved populations.

Conclusions Although the research on consumer psychoeducation is more limited than the research on family psychoeducation and its effects are more difficult to isolate, the existing evidence in ' ps.psychiatryonline.org ' April 2014 Vol. 65 No. 4

support of its effectiveness is considered high (see box on previous page). Findings suggest that consumer psychoeducation is an important building block for recovery-oriented services and shared decision-making efforts. It is also likely to be a good choice for people for whom family involvement is not feasible. Bäuml and colleagues (49) asserted that psychoeducation should be considered a “basal” intervention; routinely providing information about the illness in its initial phases empowers the individual and family to participate more actively and in a more informed way in planning and subsequent treatment. Evidence in support of family psychoeducation for adults, which has achieved positive outcomes, is also high (see box on previous page). Much of the existing research supports the effectiveness of psychoeducation for families of people with schizophrenia or other psychotic disorders, and the evidence in support of its effectiveness for families of people with bipolar disorder is growing. Multifamily groups appear to be especially popular in the literature, and the evidence base supporting their effectiveness is strong, although implementation of this approach is reported to be regrettably limited. Further research on the implementation of consumer and family psychoeducation in a variety of settings and with various treatment durations would be useful, as would evaluation of longer-term impacts (6). It will be helpful to learn more about the models that are most appropriate for people with a variety of diagnostic presentations and, in the case of family psychoeducation, various types of family dynamics. In addition, research on effective strategies for the engagement, retention, and treatment of consumers and families from various racial and ethnic backgrounds would add to our knowledge about differential effects and about which adaptations might be appropriate for people from various cultures. The evidence in support of information technology enhancements of psychoeducation models is as yet nascent and weak, but the potential for increased access to and cost-effectiveness of this approach suggests that this may be PSYCHIATRIC SERVICES

a valuable area for future development and research. Researchers should conduct studies of psychoeducation services involving participants with a wide range of psychiatric diagnoses and with substance use disorders. Studies should include a focus on children and adolescents and their families—a serious current gap in research. A 2005 review by Hoagwood (50) of psychoeducation for children and adolescents and their families found only three studies that were adequately designed; however, each study examined a different intervention. We note Hoagwood’s exhortation that models used with families of adult consumers should “be imported into the field of children’s mental health services research” and “tested rigorously.” Further investigation into the optimal duration and intensity of the range of psychoeducation models for people with various clinical presentations would also be helpful. In addition, it will be important to examine the costeffectiveness of consumer group models and of multifamily group models, which have the potential to provide stronger peer support at less cost than models for individual consumers and families. Current research demonstrates the value of psychoeducation for consumers and families in the behavioral health continuum of care. It is important that consumers and their families work carefully with practitioners to determine which model (consumer psychoeducation or family psychoeducation) and format (alone or in groups) are likely to work best for them. On the basis of the supporting evidence, psychoeducation is an important benefit in health plans that are increasingly responsible for serving people with chronic and serious mental illnesses. In many cases, these plans may find consumer and family group models to be more economical as well as more effective than individual models, despite logistical barriers to engagement and attendance. Family members and other caregivers of adults with serious behavioral health problems should regard family psychoeducation as an important and routine component of treatment, as should state mental health authorities

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and third-party payers. Special emphasis on these models for support of medication adherence is warranted. Psychoeducation is also an important component of shared decision making, and its significance in the modern health care system is likely to grow as the implementation of supported, selfdirected care models increases. Acknowledgments and disclosures Development of the Assessing the Evidence Base Series was supported by contracts HHSS283200700029I/HHSS28342002T, HHSS283200700006I/HHSS28342003T, and HHSS2832007000171/HHSS28300001T from 2010 through 2013 from the Substance Abuse and Mental Health Services Administration (SAMHSA). The authors acknowledge the valuable contributions of Kevin Malone, B.A., from SAMHSA; John O’Brien, M.A., from the Centers for Medicare & Medicaid Services; Garrett Moran, Ph.D., from Westat; and John Easterday, Ph.D., Linda Lee, Ph.D., Rosanna Coffey, Ph.D., and Tami Mark, Ph.D., from Truven Health Analytics. The views expressed in this article are those of the authors and do not necessarily represent the views of SAMHSA. The authors report no competing interests.

References 1. Dixon L, Adams C, Lucksted A: Update on family psychoeducation for schizophrenia. Schizophrenia Bulletin 26:5–20, 2000 2. McFarlane WR, Dixon L, Lukens E, et al: Family psychoeducation and schizophrenia: a review of the literature. Journal of Marital and Family Therapy 29:223–245, 2003 3. Zaretsky A: Targeted psychosocial interventions for bipolar disorder. Bipolar Disorders 5(suppl 2):80–87, 2003 4. Dixon LB, Dickerson F, Bellack AS, et al: The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements. Schizophrenia Bulletin 36:48–70, 2010 5. Fernandez RS, Evans V, Griffiths RD, et al: Educational interventions for mental health consumers receiving psychotropic medication: a review of the evidence. International Journal of Mental Health Nursing 15:70–80, 2006 6. Dixon L, McFarlane WR, Lefley H, et al: Evidence-based practices for services to families of people with psychiatric disabilities. Psychiatric Services 52:903–910, 2001 7. Miklowitz DJ, Scott J: Psychosocial treatments for bipolar disorder: cost-effectiveness, mediating mechanisms, and future directions. Bipolar Disorders 11(suppl 2):110– 122, 2009 8. Dixon L, Lucksted A, Stewart B, et al: Outcomes of the peer-taught 12-week Family-to-Family education program for severe mental illness. Acta Psychiatrica Scandinavica 109:207–215, 2004

427

9. National Registry of Evidence-Based Programs and Practices: Intervention Summary. Psychoeducational Multifamily Groups. Rockville, Md, Substance Abuse and Mental Health Services Administration, 2006. Available at www.nrepp.samhsa. gov/ViewIntervention.aspx?id=120. Accessed Sept 19, 2013 10. Falloon IR, Boyd JL, McGill CW, et al: Family management in the prevention of exacerbations of schizophrenia: a controlled study. New England Journal of Medicine 306:1437–1440, 1982 11. Falloon IR, Boyd JL, McGill CW: Family Care of Schizophrenics. New York, Guilford, 1984 12. Liberman RP, Cardin V, McGill CW, et al: Behavioral family management of schizophrenia: Clinical outcome and costs. Psychiatric Annals 17:610–619,1987 13. Murray-Swank AB, Dixon L: Family psychoeducation as an evidence-based practice. CNS Spectrums 9:905–912, 2004 14. Pitschel-Walz G, Leucht S, Bauml J, et al: The effect of family interventions on relapse and rehospitalization in schizophrenia: a meta-analysis. Schizophrenia Bulletin 27:73–92, 2001 15. Rizvi S, Zaretsky AE: Psychotherapy through the phases of bipolar disorder: evidence for general efficacy and differential effects. Journal of Clinical Psychology 63:491–506, 2007

nents of first-episode psychosis services. Psychiatric Services 64:452–457, 2013 24. Lincoln TM, Wilhelm K, Nestoriuc Y: Effectiveness of psychoeducation for relapse, symptoms, knowledge, adherence and functioning in psychotic disorders: a metaanalysis. Schizophrenia Research 96: 232–245, 2007 25. Justo LP, Soares BG, Calil HM: Family interventions for bipolar disorder. Cochrane Database of Systematic Reviews 4:CD005167, 2007 26. Lehman AF, Steinwachs DM: Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations. Schizophrenia Bulletin 24:1–10, 1998 27. Kreyenbuhl J, Buchanan RW, Dickerson FB, et al: The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. Schizophrenia Bulletin 36:94–103, 2010 28. Miklowitz DJ: A review of evidence-based psychosocial interventions for bipolar disorder. Journal of Clinical Psychiatry 67 (suppl 11):28–33, 2006 29. Välimäki M, Hätönen H, Lahti M, et al: Information and communication technology in patient education and support for people with schizophrenia. Cochrane Database of Systematic Reviews 10: CD007198, 2012

Insight and Psychosis. Edited by Amador XF, David AS. New York, Oxford University Press, 1998 38. Penn DL, Mueser KT: Research update on the psychosocial treatment of schizophrenia. American Journal of Psychiatry 153: 607–617, 1996 39. Rummel-Kluge C, Kissling W: Psychoeducation in schizophrenia: new developments and approaches in the field. Current Opinion in Psychiatry 21:168–172, 2008 40. Zaretsky AE, Rizvi S, Parikh SV: How well do psychosocial interventions work in bipolar disorder? Canadian Journal of Psychiatry 52: 14–21, 2007 41. Colom F, Vieta E, Martinez-Aran A, et al: A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Archives of General Psychiatry 60:402–407, 2003 42. Perry A, Tarrier N, Morriss R, et al: Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment. British Medical Journal 318:149–153, 1999 43. Simon GE, Ludman EJ, Unützer J, et al: Randomized trial of a population-based care program for people with bipolar disorder. Psychological Medicine 35: 13–24, 2005

16. Lyman DR, Kurtz MM, Farkas M, et al: Skill building: assessing the evidence. Psychiatric Services, 2014; doi 10.1176/appi. ps.201300251

30. Shimazu K, Shimodera S, Mino Y, et al: Family psychoeducation for major depression: randomised controlled trial. British Journal of Psychiatry 198:385–390, 2011

44. McFarlane WR, Lukens E, Link B, et al: Multiple-family groups and psychoeducation in the treatment of schizophrenia. Archives of General Psychiatry 52: 679–687, 1995

17. Dougherty RH, Lyman DR, George P, et al: Assessing the evidence base for behavioral health services: introduction to the series. Psychiatric Services, 2013; doi 10.1176/appi.ps.201300214

31. Kopelowicz A, Zarate R, Wallace CJ, et al: The ability of multifamily groups to improve treatment adherence in Mexican Americans with schizophrenia. Archives of General Psychiatry 69:265–273, 2012

45. McFarlane WR, Link B, Dushay R, et al: Psychoeducational multiple family groups: four-year relapse outcome in schizophrenia. Family Process 34:127–144, 1995

18. Lolich M, Vázquez GH, Alvarez LM, et al: Psychosocial interventions in bipolar disorder: a review. Actas Españolas de Psiquiatría 40:84–92, 2012

32. Baucom DH, Shoham V, Mueser KT, et al: Empirically supported couple and family interventions for marital distress and adult mental health problems. Journal of Consulting and Clinical Psychology 66:53–88, 1998

19. Beynon S, Soares-Weiser K, Woolacott N, et al: Psychosocial interventions for the prevention of relapse in bipolar disorder: systematic review of controlled trials. British Journal of Psychiatry 192:5–11, 2008 20. Rabovsky K, Trombini M, Allemann D, et al: Efficacy of bifocal diagnosis-independent group psychoeducation in severe psychiatric disorders: results from a randomized controlled trial. European Archives of Psychiatry and Clinical Neuroscience 262:431–440, 2012 21. Chien WT, Leung SF, Chu CSK: A nurse-led, needs-based psycho-education intervention for Chinese patients with first-onset mental illness. Contemporary Nurse 40:194–209, 2012 22. Xia J, Merinder LB, Belgamwar MR: Psychoeducation for schizophrenia. Cochrane Database of Systematic Reviews 6:CD002831, 2011 23. Addington DE, McKenzie E, Norman R, et al: Essential evidence-based compo-

428

33. Dixon LB, Lehman AF: Family interventions for schizophrenia. Schizophrenia Bulletin 21:631–643, 1995 34. Falloon IR, Held T, Coverdale JH, et al: Family interventions for schizophrenia: a review of long-term benefits of international studies. Psychiatric Rehabilitation Skills 3:268–290, 1999 35. Goldstein MJ, Miklowitz DJ: The effectiveness of psychoeducational family therapy in the treatment of schizophrenic disorders. Journal of Marital and Family Therapy 21:361–376, 1995 36. Lam DH: Psychosocial family intervention in schizophrenia: a review of empirical studies. Psychological Medicine 21:423–441, 1991 37. McFarlane WR, Lukens EP: Insight, families, and education: an exploration of the role of attribution in clinical outcome; in

PSYCHIATRIC SERVICES

46. Scott J, Colom F, Popova E, et al: Longterm mental health resource utilization and cost of care following group psychoeducation or unstructured group support for bipolar disorders: a cost-benefit analysis. Journal of Clinical Psychiatry 70: 378–386, 2009 47. Cuijpers P: The effects of family interventions on relatives’ burden: a metaanalysis. Journal of Mental Health 8: 275–285, 1999 48. Telles C, Karno M, Mintz J, et al: Immigrant families coping with schizophrenia: behavioural family intervention v. case management with a low-income Spanishspeaking population. British Journal of Psychiatry 167:473–479, 1995 49. Bäuml J, Froböse T, Kraemer S, et al: Psychoeducation: a basic psychotherapeutic intervention for patients with schizophrenia and their families. Schizophrenia Bulletin 32(suppl 1):S1–S9, 2006 50. Hoagwood KE: Family-based services in children’s mental health: a research review and synthesis. Journal of Child Psychology and Psychiatry, and Allied Disciplines 46: 690–713, 2005

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