Schizophrenia Bulletin vol. 40 no. 3 pp. 497–498, 2014 doi:10.1093/schbul/sbu039 Advance Access publication March 17, 2014
Cochrane Corner
Brief Family Intervention for Schizophrenia
Uzuazomaro Okpokoro*,1 and Stephanie Sampson2
*To whom correspondence should be addressed; Mental Health Studies, Division of Psychiatry, University of Nottingham, Room B21, Sir Colin Campbell Building, Jubilee Campus, Nottingham, NG7 2TU, UK; e-mail: [email protected]
Background
estimated a mean difference (MD) between groups and their 95% confidence intervals. We used GRADE to assess quality of evidence for main outcomes of interest and create a summary of findings table. We assessed risk of bias for included studies.
Supportive, positive family environments have been shown to improve outcomes for patients with schizophrenia in contrast with family environments that express high levels of criticism, hostility, or overinvolvement, which have poorer outcomes and have more frequent relapses. Forms of psychosocial intervention, designed to promote positive environments and reduce these levels of expressed emotions within families, are now widely used.
Main Results Four studies randomizing 163 people could be included in the review. It is not clear if brief family intervention reduces the utilization of health services by patients, as most results are equivocal and only 1 study reported data for the primary outcome of “hospital admission” (n = 30, 1 randomized clinical trial [RCT], RR 0.50, 95% CI 0.22–1.11, very low-quality evidence). Data for “relapse” are also equivocal (n = 40, 1 RCT, RR medium term 0.50, 95% CI 0.10–2.43, low-quality evidence). However, data for the family outcome of “understanding of family member” significantly favored brief family intervention (n = 70, 1 RCT, MD 14.90, 95% CI 7.20–22.60, very low-quality evidence). No study reported data for “days in hospital,” “adverse events,” “medication compliance,” “quality of life,” “satisfaction with care,” or any economic outcomes (table 1).
Objectives To assess the effects of brief family interventions (5 sessions or less) for people with schizophrenia or schizophrenia-like conditions. Search Methods We searched the Cochrane Schizophrenia Group Trials Register (July 2012) that is based on regular searches of CINAHL, EMBASE, MEDLINE, and PsycINFO. We inspected references of all identified studies for further trials. We contacted authors of trials for additional information.
Authors’ Conclusions
Selection Criteria
The findings of this review are limited because data are so sparse. However, the importance of a brief version of family therapy should be properly investigated within well-designed, conducted, and reported trials with enough power to inform clinical practice. Please see Cochrane review for full details.
All relevant randomized studies that compared brief family-oriented psychosocial interventions with standard care, focusing on families of people with schizophrenia or schizoaffective disorder. Data Collection and Analysis
Reference
We reliably selected, quality-assessed and extracted data from studies. For binary outcomes, we calculated standard estimates of relative risk (RR) and their 95% confidence intervals (CI). For continuous outcomes, we
1. Okpokoro U, Adams CE, Sampson S. Family intervention (brief) for schizophrenia. Cochr Database Syst Rev. 2012; CD009802. doi:10.1002/14651858.CD009802
© The Author 2014. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: [email protected]
497
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at University of California, San Francisco on March 24, 2015
1 Division of Psychiatry, University of Nottingham, Nottingham, UK; 2Cochrane Schizophrenia Group, University of Nottingham, Nottingham, UK
No study reported/measured this outcome Mean family Mean family understanding understanding score score in control in intervention group group 104.2 14.9 higher (7.2 to 22.6 points higher) No study reported/measured this outcome
RR 0.5 (0.1 to 2.43)
RR 0.5 (0.22 to 1.11)
Relative Effect (95% CI)
70 (1 study)
40 (1 study)
30 (1 study)
No of Participants (Studies)
⊕⊝⊝⊝ very lowe,f
⊕⊕⊝⊝ lowc,d
⊕⊝⊝⊝ very lowb,c
Quality of the Evidence (GRADE)
Comments
Note: RR, relative risk. a Mean baseline risk presented for single study. b Risk of bias: “very serious”—no blinding of participants or study personnel; 29% participant data not accounted; statistical data not reported. c Imprecision: “serious”—95% confidence intervals for best estimate of effect include both “no effect” and appreciable benefit/harm. d Risk of bias: “serious”—no blinding of participants or study personnel. e Risk of bias: “very serious”—no mention of allocation concealment/blinding; attrition at 65%—only n = 34 out of N = 200 completed the study and were included in data and analysis. f Indirectness: “serious”—scale-derived data.
Economic outcomes
333 per 1000 (147 to 740)
667 per 1000a
Service utilization—hospital admission follow-up: 12 mo Service utilization—days in hospital Global state—relapse follow-up: 4 mo Global state—compliance with medication Quality of life/satisfaction with care Family outcome—understanding, average Patient Rejection Scale endpoint score (high = more acceptance) follow-up: 2 mo No study reported/measured this outcome 200 per 1000a 100 per 1000 (20 to 486) No study reported/measured this outcome
Brief Family Intervention
Standard Care
Corresponding Risk
Outcomes
Assumed Risk
Illustrative Comparative Risks* (95% CI)
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at University of California, San Francisco on March 24, 2015
498
Brief Family Intervention vs Standard Care for Schizophrenia
Table 1. Summary of Findings Table
U. Okpokoro & S. Sampson
Cochrane Corner
Brief Family Intervention for Schizophrenia
Uzuazomaro Okpokoro*,1 and Stephanie Sampson2
*To whom correspondence should be addressed; Mental Health Studies, Division of Psychiatry, University of Nottingham, Room B21, Sir Colin Campbell Building, Jubilee Campus, Nottingham, NG7 2TU, UK; e-mail: [email protected]
Background
estimated a mean difference (MD) between groups and their 95% confidence intervals. We used GRADE to assess quality of evidence for main outcomes of interest and create a summary of findings table. We assessed risk of bias for included studies.
Supportive, positive family environments have been shown to improve outcomes for patients with schizophrenia in contrast with family environments that express high levels of criticism, hostility, or overinvolvement, which have poorer outcomes and have more frequent relapses. Forms of psychosocial intervention, designed to promote positive environments and reduce these levels of expressed emotions within families, are now widely used.
Main Results Four studies randomizing 163 people could be included in the review. It is not clear if brief family intervention reduces the utilization of health services by patients, as most results are equivocal and only 1 study reported data for the primary outcome of “hospital admission” (n = 30, 1 randomized clinical trial [RCT], RR 0.50, 95% CI 0.22–1.11, very low-quality evidence). Data for “relapse” are also equivocal (n = 40, 1 RCT, RR medium term 0.50, 95% CI 0.10–2.43, low-quality evidence). However, data for the family outcome of “understanding of family member” significantly favored brief family intervention (n = 70, 1 RCT, MD 14.90, 95% CI 7.20–22.60, very low-quality evidence). No study reported data for “days in hospital,” “adverse events,” “medication compliance,” “quality of life,” “satisfaction with care,” or any economic outcomes (table 1).
Objectives To assess the effects of brief family interventions (5 sessions or less) for people with schizophrenia or schizophrenia-like conditions. Search Methods We searched the Cochrane Schizophrenia Group Trials Register (July 2012) that is based on regular searches of CINAHL, EMBASE, MEDLINE, and PsycINFO. We inspected references of all identified studies for further trials. We contacted authors of trials for additional information.
Authors’ Conclusions
Selection Criteria
The findings of this review are limited because data are so sparse. However, the importance of a brief version of family therapy should be properly investigated within well-designed, conducted, and reported trials with enough power to inform clinical practice. Please see Cochrane review for full details.
All relevant randomized studies that compared brief family-oriented psychosocial interventions with standard care, focusing on families of people with schizophrenia or schizoaffective disorder. Data Collection and Analysis
Reference
We reliably selected, quality-assessed and extracted data from studies. For binary outcomes, we calculated standard estimates of relative risk (RR) and their 95% confidence intervals (CI). For continuous outcomes, we
1. Okpokoro U, Adams CE, Sampson S. Family intervention (brief) for schizophrenia. Cochr Database Syst Rev. 2012; CD009802. doi:10.1002/14651858.CD009802
© The Author 2014. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: [email protected]
497
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at University of California, San Francisco on March 24, 2015
1 Division of Psychiatry, University of Nottingham, Nottingham, UK; 2Cochrane Schizophrenia Group, University of Nottingham, Nottingham, UK
No study reported/measured this outcome Mean family Mean family understanding understanding score score in control in intervention group group 104.2 14.9 higher (7.2 to 22.6 points higher) No study reported/measured this outcome
RR 0.5 (0.1 to 2.43)
RR 0.5 (0.22 to 1.11)
Relative Effect (95% CI)
70 (1 study)
40 (1 study)
30 (1 study)
No of Participants (Studies)
⊕⊝⊝⊝ very lowe,f
⊕⊕⊝⊝ lowc,d
⊕⊝⊝⊝ very lowb,c
Quality of the Evidence (GRADE)
Comments
Note: RR, relative risk. a Mean baseline risk presented for single study. b Risk of bias: “very serious”—no blinding of participants or study personnel; 29% participant data not accounted; statistical data not reported. c Imprecision: “serious”—95% confidence intervals for best estimate of effect include both “no effect” and appreciable benefit/harm. d Risk of bias: “serious”—no blinding of participants or study personnel. e Risk of bias: “very serious”—no mention of allocation concealment/blinding; attrition at 65%—only n = 34 out of N = 200 completed the study and were included in data and analysis. f Indirectness: “serious”—scale-derived data.
Economic outcomes
333 per 1000 (147 to 740)
667 per 1000a
Service utilization—hospital admission follow-up: 12 mo Service utilization—days in hospital Global state—relapse follow-up: 4 mo Global state—compliance with medication Quality of life/satisfaction with care Family outcome—understanding, average Patient Rejection Scale endpoint score (high = more acceptance) follow-up: 2 mo No study reported/measured this outcome 200 per 1000a 100 per 1000 (20 to 486) No study reported/measured this outcome
Brief Family Intervention
Standard Care
Corresponding Risk
Outcomes
Assumed Risk
Illustrative Comparative Risks* (95% CI)
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at University of California, San Francisco on March 24, 2015
498
Brief Family Intervention vs Standard Care for Schizophrenia
Table 1. Summary of Findings Table
U. Okpokoro & S. Sampson
