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Psychoeducational intervention and prevention of relapse among schizophrenic disorders in the Italian community psychiatric network

Psychoeducational intervention and prevention of relapse among schizophrenic disorders in the... Background: The lack of compliance is associated with an increased risk of hospitalization and switching or augmentation of therapy when compared with being compliant. A synergy of drug therapy and psychosocial interventions can give more benefits in treatment. Methods: A perspective study was conducted on 150 patients with schizophrenia over 15 centers in Italy. The experimental group was treated with drug therapy, traditional psychosocial and psychoeducation for the patients and their families, while the control group received traditional psychosocial and drug intervention over 1 year. Results: The experimental group showed a significant statistical improvement (p < 0,05) in almost all the scales that have been assessed (BPRS, SAPS, SANS, SIMPSON-ANGUS SCALE, LANCASHIRE QL SCALE). Significant was the reduction of the number of hospitalizations and of days of hospital stay. Conclusion: As it is shown in international literature, psychoeducational intervention with schizophrenic patients and their families can reduce the occurrence of relapse. 1. Background symptomatic acute phases, to bring the patient to comply The recent changes in the treatment of schizophrenic dis- with the prescribed treatment plan, to restore a certain orders allow us to use both traditional and atypical antip- social and working functioning and to reach a better qual- sychotic drugs, and psychosocial interventions with a ity of life. reliable efficacy, in treating the symptoms of both positive and negative schizophrenia [1-11]. Among the psychosocial interventions, the psychoeduca- tional ones for the patients and their family, have been The clear aim of the treatment of such disorders is not considered to be the most promising and successful only to control the symptoms, but it is also to prevent new within the last thirty years [12-14]. Page 1 of 12 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2007, 3:7 http://www.cpementalhealth.com/content/3/1/7 The basic principles of the psychoeducational interven- The positive effects of such psychoeducational interven- tions are represented by simple, correct and complete tion on the patients and their family, are not only a information about the disorder and its possible treatment decrease of new symptomatic acute phases, but also a methods [15]. decrease of the number of hospitalizations and a better compliance with the treatment [27] especially the drug The goal is also to try to make both the patients and their one [1,29-33]. family aware of those problems, which are related with the disorder, the communication difficulties and the most It is generally believed that people affected by schizophre- appropriate management of the stressors and life events. nia that regularly take prescribed antipsychotic drugs, show a faster and more complete remission, and a lower All of these elements allow the patients and their family to risk of relapse [34]. become more conscious and better able to deal with prob- lems, fostering therefore an easier and more effective Since the 1970s, many studies have confirmed that the course of the illness, especially when the psychoeduca- participation in a long term and stable drug treatment can tional interventions are associated with an appropriate better prevent relapse compared to a more irregular and and long-term drug treatment [11,16]. discontinuous drug treatment. However, unfortunately, only 50% of people affected by schizophrenia undergo A review of those studies published in this field since the regular an adequate drug treatments for a set period of beginning of the 1980s, confirms that the use of psycho- time [35,36]. social treatments and combined with an appropriate long term antipsychotic therapy, can reduce the percentage of On the other hand it is generally agreed that not all relapse [17] in a year to about 54%. If psychoeducational patients respond the same to drug treatments and that interventions are carried out with patients and their fami- those treatments do not show the same results with every lies [18], in addition to this assertive community patient [37]. approach, the yearly relapses further decrease to 27% [19]. In many cases the benefits of such drug treatment are only These psychoeducational interventions follow a cogni- partial and therefore they are not very well liked by the tive-behavioral model. This was probably one of the main patients and by their families [38]. causes for the difficult and slow acceptance and popular- ity of such new therapeutic interventions by the Italian Several studies have shown that approximately one-third community mental health centers. In fact, still today, of patients are fully compliant, one-third partially compli- despite their overwhelming success rate and their spread ant, and the final one third entirely non-compliant. [39- among many psychiatric staffs in the world, the psychoed- 41]. ucational approaches are still viewed with suspicion, and many Italian psychiatrists are openly against them. The Another study demonstrated that 54,5% of patients were open and latent fear is accepting therapeutic models compliant and that 39,0% were partially compliant. Par- which appear to be too simple and limiting, oriented tial compliance was associated with an increased risk of more toward a biological approach of the disorder, which hospitalization and switching or augmentation of therapy is far from the Italian mental health community and tra- when compared with being compliant [42]. dition. On the other hand, most of psychiatrist in Italy have adopted a psychodynamic oriented approach, A decrease in compliance predicted an increase in PANSS though filtered through the requirements established by which corresponds to a worsening of symptoms [43]. social psychiatry and by the "setting" of the public psychi- atric services after the Basaglia reform. Often, the idea of A low compliance also predicts an increase risk of hospi- introducing new treatment techniques with the most crit- talization: even small gaps in therapy (1–10 days) ical patients and their family members is viewed as an increased the likelihood of hospitalization by twice, attack to already consolidated effective procedures and to whereas larger gaps in therapy (>30 days) increased the rooted cultural models [20]. likelihood of hospitalization by four times [43]. However, the total effectiveness of the psychoeducational The psychoeducational interventions can facilitate schizo- interventions cannot be disputed: in fact more than 20 phrenic patients in gaining the necessary skills to effec- researches around the world have demonstrated the effec- tively manage a drug treatment. tiveness and the encouraging cost-benefit relationship [21-26] for a group of more than 1500 patients [27]. In order to have the patient comply to an antipsychotic drug treatment in a more appropriate way, it is necessary Page 2 of 12 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2007, 3:7 http://www.cpementalhealth.com/content/3/1/7 to: 1) assess thoroughly the patient's background in terms group), while the second half of the sample underwent a of past drug therapies and of those factors which might treatment, which included also, along with the traditional have prevented the compliance; 2) use, whenever it is pos- psychosocial interventions, a psychoeducational treat- sible, a "contractual" approach, in which any potential ment. Traditional treatment together with psychoeduca- change from its original layout can easily be discussed tion was able to reduce of 45% the number of with the patient; 3) educate the patients and the family hospitalization [1,54]. members on the disorder and its characteristics, and on the prevention of potential relapses, making them aware In Italy a an open, controlled multicentric research was of the risks and the benefits of antipsychotic drugs; 4) conducted in 15 Italian Community Mental Health Cent- maintain, whenever it is possible, the control over those ers (Public Mental Health Departments and University patients who may temporarily neglect and/or refuse the Psychiatric Clinics), for the duration of 1 year, excluding drug treatment, still offering them alternative solutions the screening phases. In each CMHC, after each screening [1,44]. phase, the patients were blindly randomized by the exper- imenter into two groups. The control group (of a total of Informative, short term psychoeducational interventions 66 people) was treated with a standard procedure (antip- seem to be not as effective in the long run, in maintaining sychotic drug treatment and assertive community treat- the compliance[28,45-47]. ment), while the study group (69 patients) received, traditional psychosocial intervention, antipsychotic drug On the other hand, a more structured and prolonged psy- treatment and a psychoeducational program. Such sam- choeducational treatment for patients and their families, ple, comprised of patients and their families, participated seem to be more effective in the long run [4,10,48-53]. separately to 8 different parallel psychoeducational meet- ings, of 60–90 minutes each. Such meetings were charac- 2. Methods terized by an overlapping informative content, and were 2.1 Design of the study run by two psychiatric operators (mainly by a psychiatrist This study was conducted in Italy, with the goal of trying and a psychiatric nurse). to identify the most effective tools in the prevention of relapse among those affected by schizophrenia. The scales assessment was carried out at the beginning of the trial, after 6 months (T2), and 12 months (T4). At the The main objective of the study was to assess the effective- end of the study the parameters "Number of hospitaliza- ness of the combination of a long term drug therapy and tions" and "Total number of hospital days" were checked. a psychoeducational intervention, on people affected by Each time drug recording and vital parameters were schizophrenia in reducing relapses in terms of number of assessed. (Tab 1, Research protocol) hospitalisations and clinical parameters. 2.2 Patients The Italian protocol was developed based on the model of 150 patients took part in this study. Their age ranged from a study conducted in Munich between 1990 and 1994, by 18 and 45 years. They were all diagnosed with schizophre- Kissling and Bauml, with a sample of 236 patients [1,54]. nia, in agreement with the DSM IV (Diagnostic and Statis- tical Manual of Mental Disorders, fourth edition) and the In this study, half of the patients affected by schizophrenia ICD 10 (International Classification of Diseases, tenth underwent a traditional drug treatment (the control Table 1: Research protocol Time T-x First screening phase Time T 0 - Vital parameters - Analysis of the drug treatment characteristics and Drug treatment registration - Assessment scales administration Time T 1 (After 3 months) - Vital parameters Time T 2 (After 6 months) - Drug treatment registration - Assessment scales administration Time T 3 (After 9 months) - Vital parameters Time T 4 (After 12 months) - Vital parameters - Assessment scales administration - Control for the re-hospitalization rate (Number of hospitalizations, Total number of hospital days) Page 3 of 12 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2007, 3:7 http://www.cpementalhealth.com/content/3/1/7 edition) and were undergoing a standardized therapy in 2.6 Statistical methods terms of types of drugs and dosages. All of the data was elaborated and statistically measured using the SAS procedure v 6.12. The basal homogeneity of A set of criteria for the exclusion from the study included: the groups was measured for both the demographic char- acute psychosis, a substance abuse problem, organic fac- acteristics and the measuring scales, using the Wilcoxon's tors that could interfere with the clinical condition, the non-parametric test. patients' current participation in psychoeducational and structured treatments, or their participation in the last two The measurement within treatments was conducted tak- years. ing in consideration the starting and ending time of the treatment: the significance of the difference was measured The analysis of the participants has shown no significant using the Sign Rank Test. clinical and socio-demographic differences between the two groups. 135 patients finished the study; 15 dropped The treatments were compared using an ANOVA model, out for different reasons unrelated to the study. in which the fixed effects were the treatment and the cent- ers; the assessment of the differences was done on the LS 2.3 Antipsychotic drug treatment means (means calculated with the least squares' method) Both groups followed the antipsychotic drug treatment using the LSD test of the PRCO GLM. using traditional and atypical antipsychotic drugs, admin- 2.7 Consent istered alone or combined. The current dosage was moni- tored every 6 months, from the beginning of the study. An The study was approved by the ethical committee and the equal percentage of patients in both the control and the patient gave written informed consent. study groups, received also, during the study, some depot or "long acting" (haloperidol decanoate, fluphenazine 3. Results decanoate, zuclopentixol decanoate) anti-psychotic 3.1 Socio demographic and clinical parameters drugs. The two subgroups of subjects participating in the test have the same clinical and socio-demographic characteris- 2.4 Psychiatric assessment Scales tics. The percentage of male vs female and the age groups The following scales were administered during the study: stratification in both groups appears to be similar, and the BPRS (Brief Psychiatric Rating Scale), SAPS (Scale for differences are not of statistical significance. (Fig 1, Age ; Assessment of Positive Symptoms), SANS (Scale for Fig 2, Sex) Assessment of Negative Symptoms), Sympson and Angus Scale, ROMI (Rating of Medication Influences) and the Heart rate, blood pressure and body weight measure- Lancaster QL (Lancaster Quality of Life Profile). ments have remained the same during the entire treat- ment program. (Tab. 2, Vital parameters) 2.5 Psychoeducational program The standardized psychoeducational program, managed Diagnosis according to the DSM IV has brought to a fur- through an interactive educational method, took place in ther subdivision of the different subtypes of schizophre- 8 sessions, in which the following topics were covered: nia, the main one being the paranoid type, respectively 1. Introduction 2. What is schizophrenia? 3. What causes schizophrenia? 4. How to treat schizophrenia? 5. Psychosocial treatment strategies 6. Preventing relapses 7. The role of the family Age Figure 1 Age. 8. Conclusion Page 4 of 12 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2007, 3:7 http://www.cpementalhealth.com/content/3/1/7 T4 with 16.54 points of difference (p < 0.05). The differ- ence between the groups was statistically significant in favor to the study group. (p < 0.05). (Fig. 3, BPRS scale) The detailed analysis of the single items of the BPRS scale, allows to highlight the items that changed most. The study group has shown a better improvement (p < 0.05) in delayed emotional flattening, anxiety, emotional withdrawal, dis- tractibility, thought disorganization, lack of collabora- tion, artificial attitude. The motor skill and the excitability items decreased equally in both groups (p > 0.05) (Tab. 5, BPRS scale: assessment of item "emotion"). Se Figure 2 x Sex. The study group had a significant improvement (p < 0.05) in items of the BPRS Behaviour subscale such as: depres- sion, personal neglect, somatic preoccupation, and unu- sual thought process. (Tab. 6, BPRS scale: assessment of 40% in the study group and 43% in the control group item: "behavior") (difference n.s.). (Tab. 3, Diagnosis) SAPS Scale was used to asses positive symptoms (halluci- Time from the first diagnosis, the years of treatment, the nations, delusions, strange behavior, thought disorder). number of hospitalizations, and the current psychophar- The total score has shown a statistical significant decrease macological treatment, were also kept under considera- for both groups. The study group changed from 47.2 to tion. 32.57 points with a difference of 15.7 points (<0.05); the control group varied from 48.46 to 41.71 points with a All of the parameters have resulted substantially homoge- 6.75 point difference. A highly significant difference was neous and there was no substantial statistical significance found between the two groups (<0.001). (Fig. 4, SAPS between the two study groups. (Tab. 4, Clinical parame- scale) ters: years from the diagnosis, years of treatment, number of hospitalizations) A reduction in the delusional symptoms has contributed to a significant difference of 8.19 points compared with 3.2 Assessment Scales 4.74 points for the control group (p < 0.01). (Fig. 5, SAPS The BPRS showed a decrease in the gravity of symptoms scale, group of items) for both groups, but while the control group varied from a basic score of 58.27 to a score of 47.45 after 12 months The analysis of the changes in the negative symptoms was with an improvement of 10.82 points (p < 0.05). The conducted using the SANS Scale. The study group showed study group showed a score of 56.77 at T0 and of 40.23 at an improvement of 9.9 points (from 56.63, to 46.73 Table 2: Vital parameters (p > 0.05) VITAL PARAMETERS T0 T1 T2 T3 T4 Heart rate (Beats/min) STUDY 81,92 80,58 81,80 80,55 80,97 CONTROL 79,92 78,82 80,02 80,64 82,16 Systolic pressure (mmHg) STUDY 119,90 118,72 120,43 121,97 121,50 CONTROL 121,35 120,54 121,91 120,33 122,97 Diastolic pressure (mmHg) STUDY 75,73 75,09 75,33 75,97 76,33 CONTROL 75,63 75,74 75,53 74,66 77,33 Body weight (Kg) STUDY 76,04 76,52 76,78 77,26 75,90 CONTROL 76,98 77,70 76,63 78,01 79,65 Page 5 of 12 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2007, 3:7 http://www.cpementalhealth.com/content/3/1/7 Table 3: Diagnosis DIAGNOSIS STUDY (%) CONTROL (%) Schizophrenia 15 17 Disorganized Schizophrenia 9 23 Paranoid Schizophrenia 40 43 Catatonic Schizophrenia 2 0 Non-differentiated Schizophrenia 19 13 Residual Schizophrenia 15 4 points, p < 0.05) while the control group had and the control group with and increase of 0.08 points com- improvement of only 0.66 points, going from 52.8 to pared to a decrease of 1.8 points for the study group (p < 51.52. (n.s). The difference between the groups had statis- 0.05). (Fig 9, ROMI scale: reasons for non participating) tical significance (p < 0.05) (Fig. 6, SANS scale). The Simpson-Angus Scale measures the assessment of the The study group showed a significant difference in the extrapyramidal effects. Though the different treatments item distraction, showing a change of 1.62 points com- were comparable between the two groups, the study pared to the 0.81 points of change for the control group group showed a decrease of 1.36 points compared with (p < 0.05). As for the other parameters, the study group 0.97 points for the control group but the difference was scored better improvements, but the difference between non significant.(p > 0.05). (Fig. 10, Simpson-Angus scale) the groups was non significant (p > 0.05). (Fig 7, SANS scale, group of items) The quality of life at the Lancashire QL scale demonstrated ad increase for the study group of 9.52 points (from The ROMI Scale measures the reasons for participating or 100,85 points, to 110,37 points), and an improvement not in a treatment program and was assessed by both the for the control group of 0.33 points for the total scale (p < patients and the research physicians. 0.05); in particular regard to the items wellness, work, lei- sure, religion, economic situation, family relationship, The subset "Reasons for good participating to the treat- social relationship, overall wellbeing (p < 0.05). (Fig 11, ment", showed no difference between the groups (p > Lancashire QL scale) 0.05). (Fig 8, ROMI scale: reasons for participating) The percentage of the subjects hospitalized between 1 and The subset "Reasons for non participating to the treat- 3 times during the 12 months resulted to be 13% after 6 ment" such as bad relationship between the doctor and months, and 3,3% after a year with a difference of 9.7% the patient, bad relationship with the psychiatric staff, for the study group; while for the control group the varia- denial about the disease, need for current treatment, tion went from 17.7% at 6 months to 10.5% after 1 year desire for hospitalization, interference with personal with an improvement of 7,2%. The difference between activities, refusal to take medications, were improved in Table 4: Clinical parameters: years from the diagnosis, years of treatment, number of hospitalizations Clinical parameters Duration STUDY (%) CONTROL (%) Number of years from the diagnosis of schizophrenia Less than 1 year 2 4 From 1 to 5 years 31 55 From 6 to 10 years 37 19 Over 10 years 30 22 Number of years of treatment Less than l year 5 5 From 1 to 5 years 36 56 From 6 to 10 years 34 19 Over 10 years 25 20 Number of hospitalizations in the last three years None 28 26 From 1 to 3 48 47 From 4 to 6 18 19 From 7 to 10 2 6 Over 10 4 2 Page 6 of 12 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2007, 3:7 http://www.cpementalhealth.com/content/3/1/7 confirmed in the effect of the overall improvent on most clinical parameters, quality of life, relation with the staff. The different changing in BPRS over the time can suggest the role of psychoeducation in the improvement of clini- cal parameters. Both groups showed a decrease of gravity of the symptoms in the first 4 months, this can be due to the consolidated synergy between drug treatment and standard psychosocial intervention. The study group keeps on improving over the 12 months of the study and this can be related to the capacity of psychoeducation to help in handling with the symptoms, have a better thera- peutic alliance and prevent the relapse of the psychosis. The analysis of BPRS can show how much psychoeduca- tion can help in reduce certain symptoms as emotional BPRS Figure 3 scale flattening, anxiety, emotional withdrawal, distractibility, BPRS scale. thought disorganization, lack of collaboration, artificial attitude, but especially we found a particular improve- ment in depression, personal neglect, somatic preoccupa- groups showed statistical significance (p < 0.05). (Fig. 12, tion, and unusual thought process. Number of Hospitalizations) To a less extent psychoeducation can improve anxiety, There was also a decrease of mean number of days of hos- confusion, hallucinations, strange behavior, over excite- pital stays for each hospitalisationfor the study group (42 ment, grandiose feelings, hostility, suicidal tendencies. As days) compared to the control group (53 days); (p < for the suspicion item, the difference was identical for 0.05). (Fig. 13, Number of days of hospital stays) both groups: a more specific treatment can be required to improve this item. 4. Discussion 4.1 Findings The changing in both positive and negative symptoms The experimental group showed a significant statistical measured by SAPS and SANS scales evidences how psych- improvement (p < 0,05) in almost all the scales that have oeducation can give a generalized improvement over all been assessed (BPRS, SAPS, SANS, SIMPSON-ANGUS kind of symptoms. SCALE, LANCASHIRE QL SCALE). Significant was the reduction of relapse in terms of numbers of hospitaliza- The changes in ROMI scale highlighted the importance of tion, days of hospital stay and clinical parameters. This psychoeducation as shown by the improvement of the was the main objective of our study and was significantly relationship with the staff, the increase of awareness of the Table 5: BPRS scale: assessment of item "emotion" THE BPRS SCALE Assessment of each item: EMOTION GROUP CONTOL T0 T4 Diff.T0 T4 Diff, Thought disorganization 2,56 2,00 -0,56 2,34 2,18 -0,16 Emotional flattening 3,24 2,24 -7,00 2,80 2,61 -0,79 Emotional withdrawal 3,37 2,34 -7,03 3,18 2,80 -0,38 Delayed motor skills 2,53 1,42 -1,11 2,13 1,85 -0,28 Tension 3,48 2,16 -1.32 3,10 2,55 -0,55 Lack of compliance 2,11 1,29 -0,82 1,98 1,56 -0,42 Excitement 1,63 1,11 -0,52 1,99 1,44 -0,55 Distractibility 2,38 1,40 -0.98 2,30 1,80 -0,50 Motor skill hyperactivity 1,59 1,06 -0,53 1,76 1,32 -0,44 Artificial behavior 1,89 1,24 -0,65 1,92 1,67 -0,25 TOTAL Assessment 24,80 16,27 -8,53 23,47 19,77 -3,70 Page 7 of 12 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2007, 3:7 http://www.cpementalhealth.com/content/3/1/7 Table 6: BPRS scale: assessment of item: "behaviour" BPRS SCALE Assessment of each item: BEHAVIOUR GROUP CONTROL T0 T4 Diff,T0 T4 Diff. Somatic 3,23 2,08 -1,15 2,77 2,23 -0,54 preoccupation Anxiety 3,59 2,40 -1,19 3,25 2,47 -0,78 Depression 2,71 1,53 -1,18 2,52 2,08 -0,44 Suicidal tendencies 1,01 0,85 -0.16 1,11 1,03 -0,08 Feelings of guilt 2,03 1,21 -0,82 1,71 1,60 -0,11 Hostility 2,17 1,32 -0,85 2,48 1,73 -0,75 Over excitement 1,61 1.06 -0,55 1,76 1,36 -0,40 Grandiosity 1,99 1,26 -0,73 2,18 1,59 -0,59 Suspicious 2,94 1,76 -0,18 3,67 2,48 -0,19 behavior Hallucinations 2,50 1,58 -0,92 2,55 1,91 -0,64 Unusual thought 3,59 2,27 -1,32 3.23 2,45 -0,78 process Strange behavior 2,50 1,71 -0,79 2,72 2,08 -0,64 Personal neglect 2,48 1,53 -0,95 2,32 2,09 -0,23 Disorientation 1,47 1,00 -0,47 1,13 1,27 0,74 TOTAL 33,82 21,56 -12,26 33,26 26,24 -7,02 Assessment illness and the needing for treatment, the positive believe consideration the this parameter is due to the pharmaco- of the family, the prevention of relapse and the improve- therapy and it is not significantly influenced by psychoed- ment of compliance. The psychoeducational approach ucation, though the difference registered between the two has helped family members to live with patients and their groups can show that psychoeducation can teach the disorder, and, at the same time, it has highlighted the patient and the family to recognize earlier the side effects more positive qualities of patients. and relate to the doctor for changing the drug treatment. The lack of significant difference in the extrapiramidal The study group has shown an important and persistent effect (Simpson-Angus scale) can be explained with the improvement in the quality of life (Lancashire scale), while the other group had not improved over the year of SA Figure 4 PS scale SAPS Figure 5 scale, group of items SAPS scale. SAPS scale, group of items. Page 8 of 12 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2007, 3:7 http://www.cpementalhealth.com/content/3/1/7 SA Figure 6 NS scale SANS scale. the study: this difference in due to the overall benefits of RO Figure 8 MI scale: reasons for participating psychoeducation that lead to a better adherence to the ROMI scale: reasons for participating. whole program. The number of psychoeducational sessions was only 8 the scales were different, the open label design of the and we suggest this program could be further improved in study could bring some biases. A double blind study terms of number of sessions, items of discussions, role of should be recommended. the family and the patients in the process in order to better maintain the positive outcomes and the parameters that This study has several strengths. It evaluates the efficacy of have not improved. psychoeducation in the real clinical practice following a multicenter design and it analyses not only the clinical 4.3 Methodological issues parameters, the relationship and the quality of life as dif- This study has some limitations. It is a cross-sectional ferent parameters, but it also focuses on how the improve- study and cohort effect can distort the results. The number ment of compliance can lead to a reduction of relapse, as of the patients in small, so larger studies is needed to con- it is shown in international literature. firm this data. This bias could be reduced comparing the data with an international meta-analysis. 5. Conclusion A number of studies have show that a psychoeducational Though the staff carrying out psychoeducation and stand- intervention with schizophrenic patients and their fami- ard psychosocial intervention and the staff administering lies, could reduce the occurrence of relapse [2,55-58]. Such decrease seems to be related with a decrease in hos- pitalizations, with less sick days on the job, and with less social expenses [59-61]. S Figure 7 ANS scale, group of items ROMI sca Figure 9 le: reasons for non participating SANS scale, group of items. ROMI scale: reasons for non participating. Page 9 of 12 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2007, 3:7 http://www.cpementalhealth.com/content/3/1/7 Nu Figure 12 mber of Hospitalizations S Figure 10 impson-Angus scale Number of Hospitalizations. Simpson-Angus scale. associated with hospitalizations, loss of working days, The study is part of an international program whose effort tension, family and social apprehensions. is to assess the effectiveness of a psychoeducational treat- ment in the prevention of relapses, through a change in In conclusion, such multicentric experience allows us to the understanding and the acceptance of the disorder. Our confirm that the psychoeducational approach has con- study confirms improvements on most clinical parame- tributed significantly to an integrated approach that put ters, quality of life, adherence to the treatment program, together patients active role in managing symptoms, fam- reduction of relapse and number of hospitalisation. ily members participation and psychiatric staff work that led to a global improvement and a reduction of relapses A psychoeducational therapeutic approach always seems and hospitalizations. to have positive effects on both the patients and their fam- ily. In fact, results show that even short term educational- The result is an undoubtedly great advantage for the informative contents were able to improve the patients' patients, who becomes an active participant in their ther- level of compliance to the treatment program, the apeutic process, experiencing not only an improvement patients' and their family members' attitude toward the from a clinical stand point, but also an overall increased disorder, and their attitude toward the psychiatric staff. psychological wellness, reducing significantly the troubles Also, such educational approach seem to be able to and the bad feelings caused by such afflicting disorder. improve the individuals' perception of quality of life, which represents an indirect tool used to reduce self and hetero-stigmatization. The participation of family mem- bers in the study has allowed a more effective manage- ment of the patient and a better implementation of a psychosocial rehabilitation process. In addition to the unquestionable advantages of such integrative treatment plan, there is also a decrease in costs Lanca Figure 11 shire QL scale Number of days of hospital sta Figure 13 ys Lancashire QL scale. Number of days of hospital stays. Page 10 of 12 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2007, 3:7 http://www.cpementalhealth.com/content/3/1/7 21. Lam DH: Psychosocial family intervention in schizophrenia: a Competing interests review of empirical studies. Psychological Medicine 1991, The author(s) declare that they have no competing inter- 21:423-441. ests. 22. Mari JJ, Streiner D: An overview of family interventions and relapse on schizophrenia: meta – analysis on research find- ings. Psychological Medicine 1994, 24(3):565-578. Acknowledgements 23. Dixon LB, Lehman AF: Family interventions for schizophrenia. Mazzaglia Giampiero. Schizophrenia Bulletin 1995, 21(4):631-643. 24. 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Acta gram: mental health facts for families. Psychiatr Serv 2003, Psychiatr Scand 1994, 89:11-15. 54(1):35-37. 41. Buchanan A: A two year prospective study of treatment com- 17. Pekkala E, Merinder L: Psychoeducation for schizophrenia. pliance in patient with schizophrenia. Psychol Med 1992, Cochrane Database Syst Rev 2002:CD002831. 22:787-797. 18. McFarlane WR, Dixon L, Lukens E, Lucksted A: Family psychoed- 42. Eaddy M, Grogg A, Locldear J: Assessment of Compliance with ucation and schizophrenia: a review of the literature. J Marital antipsychotic Treatment and Resource Utilization in a Med- Fam Ther 2003, 29(2):223-45. icaid Population. Clinical Therapeutics 2005, 27(2):263-272. 19. Falloon IHR, Coverdale JH, Brooker C: Psychosocial interven- 43. Weiden P, Kozma C, Grogg A, Locklear J: Partial compliance and tions in schizophrenia: a review. International Journal of Mental risk of rehospitalization among California Medicaid patients Health 1996, 25:3-21. with schizophrenia. 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Mingyuan Z, Heqin Y, Chengde Y, Jianlin Y, Qingfeng Y, Peijun C, Lian- fang G, Jizhong Y, Guangya Q, Zhen W, Jianhua C, Minghua S, Jushan H, Longlin W, Yi Z, Buoying Z, Orley J, Gittelman M: Effectiveness of psychoeducation of relatives of schizophrenic patients: a prospective cohort study in five cities of China. International Journal of Mental Health 1993, 22:47-59. 57. Xiong W, Phillips MR, Hu X, Wang R, Dai Q, Kleinman J, Kleinman A: A family-based intervention for schizophrenic patients in China: a randomized controlled trial. British Journal of Psychiatry 1994, 165:239-247. 58. Rund BR, Moe L, Sollien T, Fjell A, Borchgrevink T, Hallert M, Naess PO: The psychosis project: outcome and cost-effectiveness of a psychoeducational treatment program for schizophrenic adolescents. Acta Psychiatrica Scandinavica 1994, 89:211-218. 59. Dyck DG, Hendryx MS, Short RA, Voss WD, McFarlane WR: Serv- ice use among patients with schizophrenia in psychoeduca- tional multiple-family group treatment. Psychiatric Services 2002, 53(6):749-754. 60. Herz MI, Lambert JS, Mintz J, Scott R, O'Dell SP, McCartan L, Nix G: A program for relapse prevention in schizophrenia: a con- trolled study. Archives of General Psychiatry 2000, 57(3):277-83. Publish with Bio Med Central and every 61. Hahlweg K, Wiedemann G: Principles and results of family ther- scientist can read your work free of charge apy in schizophrenia. Eur Arch Psychiatry Clin Neurosci 1999, 249(Suppl 4):108-115. "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." 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Psychoeducational intervention and prevention of relapse among schizophrenic disorders in the Italian community psychiatric network

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Springer Journals
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Copyright © 2007 by Aguglia et al; licensee BioMed Central Ltd.
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Medicine & Public Health; Psychiatry; Epidemiology
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1745-0179
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10.1186/1745-0179-3-7
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17593299
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Abstract

Background: The lack of compliance is associated with an increased risk of hospitalization and switching or augmentation of therapy when compared with being compliant. A synergy of drug therapy and psychosocial interventions can give more benefits in treatment. Methods: A perspective study was conducted on 150 patients with schizophrenia over 15 centers in Italy. The experimental group was treated with drug therapy, traditional psychosocial and psychoeducation for the patients and their families, while the control group received traditional psychosocial and drug intervention over 1 year. Results: The experimental group showed a significant statistical improvement (p < 0,05) in almost all the scales that have been assessed (BPRS, SAPS, SANS, SIMPSON-ANGUS SCALE, LANCASHIRE QL SCALE). Significant was the reduction of the number of hospitalizations and of days of hospital stay. Conclusion: As it is shown in international literature, psychoeducational intervention with schizophrenic patients and their families can reduce the occurrence of relapse. 1. Background symptomatic acute phases, to bring the patient to comply The recent changes in the treatment of schizophrenic dis- with the prescribed treatment plan, to restore a certain orders allow us to use both traditional and atypical antip- social and working functioning and to reach a better qual- sychotic drugs, and psychosocial interventions with a ity of life. reliable efficacy, in treating the symptoms of both positive and negative schizophrenia [1-11]. Among the psychosocial interventions, the psychoeduca- tional ones for the patients and their family, have been The clear aim of the treatment of such disorders is not considered to be the most promising and successful only to control the symptoms, but it is also to prevent new within the last thirty years [12-14]. Page 1 of 12 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2007, 3:7 http://www.cpementalhealth.com/content/3/1/7 The basic principles of the psychoeducational interven- The positive effects of such psychoeducational interven- tions are represented by simple, correct and complete tion on the patients and their family, are not only a information about the disorder and its possible treatment decrease of new symptomatic acute phases, but also a methods [15]. decrease of the number of hospitalizations and a better compliance with the treatment [27] especially the drug The goal is also to try to make both the patients and their one [1,29-33]. family aware of those problems, which are related with the disorder, the communication difficulties and the most It is generally believed that people affected by schizophre- appropriate management of the stressors and life events. nia that regularly take prescribed antipsychotic drugs, show a faster and more complete remission, and a lower All of these elements allow the patients and their family to risk of relapse [34]. become more conscious and better able to deal with prob- lems, fostering therefore an easier and more effective Since the 1970s, many studies have confirmed that the course of the illness, especially when the psychoeduca- participation in a long term and stable drug treatment can tional interventions are associated with an appropriate better prevent relapse compared to a more irregular and and long-term drug treatment [11,16]. discontinuous drug treatment. However, unfortunately, only 50% of people affected by schizophrenia undergo A review of those studies published in this field since the regular an adequate drug treatments for a set period of beginning of the 1980s, confirms that the use of psycho- time [35,36]. social treatments and combined with an appropriate long term antipsychotic therapy, can reduce the percentage of On the other hand it is generally agreed that not all relapse [17] in a year to about 54%. If psychoeducational patients respond the same to drug treatments and that interventions are carried out with patients and their fami- those treatments do not show the same results with every lies [18], in addition to this assertive community patient [37]. approach, the yearly relapses further decrease to 27% [19]. In many cases the benefits of such drug treatment are only These psychoeducational interventions follow a cogni- partial and therefore they are not very well liked by the tive-behavioral model. This was probably one of the main patients and by their families [38]. causes for the difficult and slow acceptance and popular- ity of such new therapeutic interventions by the Italian Several studies have shown that approximately one-third community mental health centers. In fact, still today, of patients are fully compliant, one-third partially compli- despite their overwhelming success rate and their spread ant, and the final one third entirely non-compliant. [39- among many psychiatric staffs in the world, the psychoed- 41]. ucational approaches are still viewed with suspicion, and many Italian psychiatrists are openly against them. The Another study demonstrated that 54,5% of patients were open and latent fear is accepting therapeutic models compliant and that 39,0% were partially compliant. Par- which appear to be too simple and limiting, oriented tial compliance was associated with an increased risk of more toward a biological approach of the disorder, which hospitalization and switching or augmentation of therapy is far from the Italian mental health community and tra- when compared with being compliant [42]. dition. On the other hand, most of psychiatrist in Italy have adopted a psychodynamic oriented approach, A decrease in compliance predicted an increase in PANSS though filtered through the requirements established by which corresponds to a worsening of symptoms [43]. social psychiatry and by the "setting" of the public psychi- atric services after the Basaglia reform. Often, the idea of A low compliance also predicts an increase risk of hospi- introducing new treatment techniques with the most crit- talization: even small gaps in therapy (1–10 days) ical patients and their family members is viewed as an increased the likelihood of hospitalization by twice, attack to already consolidated effective procedures and to whereas larger gaps in therapy (>30 days) increased the rooted cultural models [20]. likelihood of hospitalization by four times [43]. However, the total effectiveness of the psychoeducational The psychoeducational interventions can facilitate schizo- interventions cannot be disputed: in fact more than 20 phrenic patients in gaining the necessary skills to effec- researches around the world have demonstrated the effec- tively manage a drug treatment. tiveness and the encouraging cost-benefit relationship [21-26] for a group of more than 1500 patients [27]. In order to have the patient comply to an antipsychotic drug treatment in a more appropriate way, it is necessary Page 2 of 12 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2007, 3:7 http://www.cpementalhealth.com/content/3/1/7 to: 1) assess thoroughly the patient's background in terms group), while the second half of the sample underwent a of past drug therapies and of those factors which might treatment, which included also, along with the traditional have prevented the compliance; 2) use, whenever it is pos- psychosocial interventions, a psychoeducational treat- sible, a "contractual" approach, in which any potential ment. Traditional treatment together with psychoeduca- change from its original layout can easily be discussed tion was able to reduce of 45% the number of with the patient; 3) educate the patients and the family hospitalization [1,54]. members on the disorder and its characteristics, and on the prevention of potential relapses, making them aware In Italy a an open, controlled multicentric research was of the risks and the benefits of antipsychotic drugs; 4) conducted in 15 Italian Community Mental Health Cent- maintain, whenever it is possible, the control over those ers (Public Mental Health Departments and University patients who may temporarily neglect and/or refuse the Psychiatric Clinics), for the duration of 1 year, excluding drug treatment, still offering them alternative solutions the screening phases. In each CMHC, after each screening [1,44]. phase, the patients were blindly randomized by the exper- imenter into two groups. The control group (of a total of Informative, short term psychoeducational interventions 66 people) was treated with a standard procedure (antip- seem to be not as effective in the long run, in maintaining sychotic drug treatment and assertive community treat- the compliance[28,45-47]. ment), while the study group (69 patients) received, traditional psychosocial intervention, antipsychotic drug On the other hand, a more structured and prolonged psy- treatment and a psychoeducational program. Such sam- choeducational treatment for patients and their families, ple, comprised of patients and their families, participated seem to be more effective in the long run [4,10,48-53]. separately to 8 different parallel psychoeducational meet- ings, of 60–90 minutes each. Such meetings were charac- 2. Methods terized by an overlapping informative content, and were 2.1 Design of the study run by two psychiatric operators (mainly by a psychiatrist This study was conducted in Italy, with the goal of trying and a psychiatric nurse). to identify the most effective tools in the prevention of relapse among those affected by schizophrenia. The scales assessment was carried out at the beginning of the trial, after 6 months (T2), and 12 months (T4). At the The main objective of the study was to assess the effective- end of the study the parameters "Number of hospitaliza- ness of the combination of a long term drug therapy and tions" and "Total number of hospital days" were checked. a psychoeducational intervention, on people affected by Each time drug recording and vital parameters were schizophrenia in reducing relapses in terms of number of assessed. (Tab 1, Research protocol) hospitalisations and clinical parameters. 2.2 Patients The Italian protocol was developed based on the model of 150 patients took part in this study. Their age ranged from a study conducted in Munich between 1990 and 1994, by 18 and 45 years. They were all diagnosed with schizophre- Kissling and Bauml, with a sample of 236 patients [1,54]. nia, in agreement with the DSM IV (Diagnostic and Statis- tical Manual of Mental Disorders, fourth edition) and the In this study, half of the patients affected by schizophrenia ICD 10 (International Classification of Diseases, tenth underwent a traditional drug treatment (the control Table 1: Research protocol Time T-x First screening phase Time T 0 - Vital parameters - Analysis of the drug treatment characteristics and Drug treatment registration - Assessment scales administration Time T 1 (After 3 months) - Vital parameters Time T 2 (After 6 months) - Drug treatment registration - Assessment scales administration Time T 3 (After 9 months) - Vital parameters Time T 4 (After 12 months) - Vital parameters - Assessment scales administration - Control for the re-hospitalization rate (Number of hospitalizations, Total number of hospital days) Page 3 of 12 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2007, 3:7 http://www.cpementalhealth.com/content/3/1/7 edition) and were undergoing a standardized therapy in 2.6 Statistical methods terms of types of drugs and dosages. All of the data was elaborated and statistically measured using the SAS procedure v 6.12. The basal homogeneity of A set of criteria for the exclusion from the study included: the groups was measured for both the demographic char- acute psychosis, a substance abuse problem, organic fac- acteristics and the measuring scales, using the Wilcoxon's tors that could interfere with the clinical condition, the non-parametric test. patients' current participation in psychoeducational and structured treatments, or their participation in the last two The measurement within treatments was conducted tak- years. ing in consideration the starting and ending time of the treatment: the significance of the difference was measured The analysis of the participants has shown no significant using the Sign Rank Test. clinical and socio-demographic differences between the two groups. 135 patients finished the study; 15 dropped The treatments were compared using an ANOVA model, out for different reasons unrelated to the study. in which the fixed effects were the treatment and the cent- ers; the assessment of the differences was done on the LS 2.3 Antipsychotic drug treatment means (means calculated with the least squares' method) Both groups followed the antipsychotic drug treatment using the LSD test of the PRCO GLM. using traditional and atypical antipsychotic drugs, admin- 2.7 Consent istered alone or combined. The current dosage was moni- tored every 6 months, from the beginning of the study. An The study was approved by the ethical committee and the equal percentage of patients in both the control and the patient gave written informed consent. study groups, received also, during the study, some depot or "long acting" (haloperidol decanoate, fluphenazine 3. Results decanoate, zuclopentixol decanoate) anti-psychotic 3.1 Socio demographic and clinical parameters drugs. The two subgroups of subjects participating in the test have the same clinical and socio-demographic characteris- 2.4 Psychiatric assessment Scales tics. The percentage of male vs female and the age groups The following scales were administered during the study: stratification in both groups appears to be similar, and the BPRS (Brief Psychiatric Rating Scale), SAPS (Scale for differences are not of statistical significance. (Fig 1, Age ; Assessment of Positive Symptoms), SANS (Scale for Fig 2, Sex) Assessment of Negative Symptoms), Sympson and Angus Scale, ROMI (Rating of Medication Influences) and the Heart rate, blood pressure and body weight measure- Lancaster QL (Lancaster Quality of Life Profile). ments have remained the same during the entire treat- ment program. (Tab. 2, Vital parameters) 2.5 Psychoeducational program The standardized psychoeducational program, managed Diagnosis according to the DSM IV has brought to a fur- through an interactive educational method, took place in ther subdivision of the different subtypes of schizophre- 8 sessions, in which the following topics were covered: nia, the main one being the paranoid type, respectively 1. Introduction 2. What is schizophrenia? 3. What causes schizophrenia? 4. How to treat schizophrenia? 5. Psychosocial treatment strategies 6. Preventing relapses 7. The role of the family Age Figure 1 Age. 8. Conclusion Page 4 of 12 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2007, 3:7 http://www.cpementalhealth.com/content/3/1/7 T4 with 16.54 points of difference (p < 0.05). The differ- ence between the groups was statistically significant in favor to the study group. (p < 0.05). (Fig. 3, BPRS scale) The detailed analysis of the single items of the BPRS scale, allows to highlight the items that changed most. The study group has shown a better improvement (p < 0.05) in delayed emotional flattening, anxiety, emotional withdrawal, dis- tractibility, thought disorganization, lack of collabora- tion, artificial attitude. The motor skill and the excitability items decreased equally in both groups (p > 0.05) (Tab. 5, BPRS scale: assessment of item "emotion"). Se Figure 2 x Sex. The study group had a significant improvement (p < 0.05) in items of the BPRS Behaviour subscale such as: depres- sion, personal neglect, somatic preoccupation, and unu- sual thought process. (Tab. 6, BPRS scale: assessment of 40% in the study group and 43% in the control group item: "behavior") (difference n.s.). (Tab. 3, Diagnosis) SAPS Scale was used to asses positive symptoms (halluci- Time from the first diagnosis, the years of treatment, the nations, delusions, strange behavior, thought disorder). number of hospitalizations, and the current psychophar- The total score has shown a statistical significant decrease macological treatment, were also kept under considera- for both groups. The study group changed from 47.2 to tion. 32.57 points with a difference of 15.7 points (<0.05); the control group varied from 48.46 to 41.71 points with a All of the parameters have resulted substantially homoge- 6.75 point difference. A highly significant difference was neous and there was no substantial statistical significance found between the two groups (<0.001). (Fig. 4, SAPS between the two study groups. (Tab. 4, Clinical parame- scale) ters: years from the diagnosis, years of treatment, number of hospitalizations) A reduction in the delusional symptoms has contributed to a significant difference of 8.19 points compared with 3.2 Assessment Scales 4.74 points for the control group (p < 0.01). (Fig. 5, SAPS The BPRS showed a decrease in the gravity of symptoms scale, group of items) for both groups, but while the control group varied from a basic score of 58.27 to a score of 47.45 after 12 months The analysis of the changes in the negative symptoms was with an improvement of 10.82 points (p < 0.05). The conducted using the SANS Scale. The study group showed study group showed a score of 56.77 at T0 and of 40.23 at an improvement of 9.9 points (from 56.63, to 46.73 Table 2: Vital parameters (p > 0.05) VITAL PARAMETERS T0 T1 T2 T3 T4 Heart rate (Beats/min) STUDY 81,92 80,58 81,80 80,55 80,97 CONTROL 79,92 78,82 80,02 80,64 82,16 Systolic pressure (mmHg) STUDY 119,90 118,72 120,43 121,97 121,50 CONTROL 121,35 120,54 121,91 120,33 122,97 Diastolic pressure (mmHg) STUDY 75,73 75,09 75,33 75,97 76,33 CONTROL 75,63 75,74 75,53 74,66 77,33 Body weight (Kg) STUDY 76,04 76,52 76,78 77,26 75,90 CONTROL 76,98 77,70 76,63 78,01 79,65 Page 5 of 12 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2007, 3:7 http://www.cpementalhealth.com/content/3/1/7 Table 3: Diagnosis DIAGNOSIS STUDY (%) CONTROL (%) Schizophrenia 15 17 Disorganized Schizophrenia 9 23 Paranoid Schizophrenia 40 43 Catatonic Schizophrenia 2 0 Non-differentiated Schizophrenia 19 13 Residual Schizophrenia 15 4 points, p < 0.05) while the control group had and the control group with and increase of 0.08 points com- improvement of only 0.66 points, going from 52.8 to pared to a decrease of 1.8 points for the study group (p < 51.52. (n.s). The difference between the groups had statis- 0.05). (Fig 9, ROMI scale: reasons for non participating) tical significance (p < 0.05) (Fig. 6, SANS scale). The Simpson-Angus Scale measures the assessment of the The study group showed a significant difference in the extrapyramidal effects. Though the different treatments item distraction, showing a change of 1.62 points com- were comparable between the two groups, the study pared to the 0.81 points of change for the control group group showed a decrease of 1.36 points compared with (p < 0.05). As for the other parameters, the study group 0.97 points for the control group but the difference was scored better improvements, but the difference between non significant.(p > 0.05). (Fig. 10, Simpson-Angus scale) the groups was non significant (p > 0.05). (Fig 7, SANS scale, group of items) The quality of life at the Lancashire QL scale demonstrated ad increase for the study group of 9.52 points (from The ROMI Scale measures the reasons for participating or 100,85 points, to 110,37 points), and an improvement not in a treatment program and was assessed by both the for the control group of 0.33 points for the total scale (p < patients and the research physicians. 0.05); in particular regard to the items wellness, work, lei- sure, religion, economic situation, family relationship, The subset "Reasons for good participating to the treat- social relationship, overall wellbeing (p < 0.05). (Fig 11, ment", showed no difference between the groups (p > Lancashire QL scale) 0.05). (Fig 8, ROMI scale: reasons for participating) The percentage of the subjects hospitalized between 1 and The subset "Reasons for non participating to the treat- 3 times during the 12 months resulted to be 13% after 6 ment" such as bad relationship between the doctor and months, and 3,3% after a year with a difference of 9.7% the patient, bad relationship with the psychiatric staff, for the study group; while for the control group the varia- denial about the disease, need for current treatment, tion went from 17.7% at 6 months to 10.5% after 1 year desire for hospitalization, interference with personal with an improvement of 7,2%. The difference between activities, refusal to take medications, were improved in Table 4: Clinical parameters: years from the diagnosis, years of treatment, number of hospitalizations Clinical parameters Duration STUDY (%) CONTROL (%) Number of years from the diagnosis of schizophrenia Less than 1 year 2 4 From 1 to 5 years 31 55 From 6 to 10 years 37 19 Over 10 years 30 22 Number of years of treatment Less than l year 5 5 From 1 to 5 years 36 56 From 6 to 10 years 34 19 Over 10 years 25 20 Number of hospitalizations in the last three years None 28 26 From 1 to 3 48 47 From 4 to 6 18 19 From 7 to 10 2 6 Over 10 4 2 Page 6 of 12 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2007, 3:7 http://www.cpementalhealth.com/content/3/1/7 confirmed in the effect of the overall improvent on most clinical parameters, quality of life, relation with the staff. The different changing in BPRS over the time can suggest the role of psychoeducation in the improvement of clini- cal parameters. Both groups showed a decrease of gravity of the symptoms in the first 4 months, this can be due to the consolidated synergy between drug treatment and standard psychosocial intervention. The study group keeps on improving over the 12 months of the study and this can be related to the capacity of psychoeducation to help in handling with the symptoms, have a better thera- peutic alliance and prevent the relapse of the psychosis. The analysis of BPRS can show how much psychoeduca- tion can help in reduce certain symptoms as emotional BPRS Figure 3 scale flattening, anxiety, emotional withdrawal, distractibility, BPRS scale. thought disorganization, lack of collaboration, artificial attitude, but especially we found a particular improve- ment in depression, personal neglect, somatic preoccupa- groups showed statistical significance (p < 0.05). (Fig. 12, tion, and unusual thought process. Number of Hospitalizations) To a less extent psychoeducation can improve anxiety, There was also a decrease of mean number of days of hos- confusion, hallucinations, strange behavior, over excite- pital stays for each hospitalisationfor the study group (42 ment, grandiose feelings, hostility, suicidal tendencies. As days) compared to the control group (53 days); (p < for the suspicion item, the difference was identical for 0.05). (Fig. 13, Number of days of hospital stays) both groups: a more specific treatment can be required to improve this item. 4. Discussion 4.1 Findings The changing in both positive and negative symptoms The experimental group showed a significant statistical measured by SAPS and SANS scales evidences how psych- improvement (p < 0,05) in almost all the scales that have oeducation can give a generalized improvement over all been assessed (BPRS, SAPS, SANS, SIMPSON-ANGUS kind of symptoms. SCALE, LANCASHIRE QL SCALE). Significant was the reduction of relapse in terms of numbers of hospitaliza- The changes in ROMI scale highlighted the importance of tion, days of hospital stay and clinical parameters. This psychoeducation as shown by the improvement of the was the main objective of our study and was significantly relationship with the staff, the increase of awareness of the Table 5: BPRS scale: assessment of item "emotion" THE BPRS SCALE Assessment of each item: EMOTION GROUP CONTOL T0 T4 Diff.T0 T4 Diff, Thought disorganization 2,56 2,00 -0,56 2,34 2,18 -0,16 Emotional flattening 3,24 2,24 -7,00 2,80 2,61 -0,79 Emotional withdrawal 3,37 2,34 -7,03 3,18 2,80 -0,38 Delayed motor skills 2,53 1,42 -1,11 2,13 1,85 -0,28 Tension 3,48 2,16 -1.32 3,10 2,55 -0,55 Lack of compliance 2,11 1,29 -0,82 1,98 1,56 -0,42 Excitement 1,63 1,11 -0,52 1,99 1,44 -0,55 Distractibility 2,38 1,40 -0.98 2,30 1,80 -0,50 Motor skill hyperactivity 1,59 1,06 -0,53 1,76 1,32 -0,44 Artificial behavior 1,89 1,24 -0,65 1,92 1,67 -0,25 TOTAL Assessment 24,80 16,27 -8,53 23,47 19,77 -3,70 Page 7 of 12 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2007, 3:7 http://www.cpementalhealth.com/content/3/1/7 Table 6: BPRS scale: assessment of item: "behaviour" BPRS SCALE Assessment of each item: BEHAVIOUR GROUP CONTROL T0 T4 Diff,T0 T4 Diff. Somatic 3,23 2,08 -1,15 2,77 2,23 -0,54 preoccupation Anxiety 3,59 2,40 -1,19 3,25 2,47 -0,78 Depression 2,71 1,53 -1,18 2,52 2,08 -0,44 Suicidal tendencies 1,01 0,85 -0.16 1,11 1,03 -0,08 Feelings of guilt 2,03 1,21 -0,82 1,71 1,60 -0,11 Hostility 2,17 1,32 -0,85 2,48 1,73 -0,75 Over excitement 1,61 1.06 -0,55 1,76 1,36 -0,40 Grandiosity 1,99 1,26 -0,73 2,18 1,59 -0,59 Suspicious 2,94 1,76 -0,18 3,67 2,48 -0,19 behavior Hallucinations 2,50 1,58 -0,92 2,55 1,91 -0,64 Unusual thought 3,59 2,27 -1,32 3.23 2,45 -0,78 process Strange behavior 2,50 1,71 -0,79 2,72 2,08 -0,64 Personal neglect 2,48 1,53 -0,95 2,32 2,09 -0,23 Disorientation 1,47 1,00 -0,47 1,13 1,27 0,74 TOTAL 33,82 21,56 -12,26 33,26 26,24 -7,02 Assessment illness and the needing for treatment, the positive believe consideration the this parameter is due to the pharmaco- of the family, the prevention of relapse and the improve- therapy and it is not significantly influenced by psychoed- ment of compliance. The psychoeducational approach ucation, though the difference registered between the two has helped family members to live with patients and their groups can show that psychoeducation can teach the disorder, and, at the same time, it has highlighted the patient and the family to recognize earlier the side effects more positive qualities of patients. and relate to the doctor for changing the drug treatment. The lack of significant difference in the extrapiramidal The study group has shown an important and persistent effect (Simpson-Angus scale) can be explained with the improvement in the quality of life (Lancashire scale), while the other group had not improved over the year of SA Figure 4 PS scale SAPS Figure 5 scale, group of items SAPS scale. SAPS scale, group of items. Page 8 of 12 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2007, 3:7 http://www.cpementalhealth.com/content/3/1/7 SA Figure 6 NS scale SANS scale. the study: this difference in due to the overall benefits of RO Figure 8 MI scale: reasons for participating psychoeducation that lead to a better adherence to the ROMI scale: reasons for participating. whole program. The number of psychoeducational sessions was only 8 the scales were different, the open label design of the and we suggest this program could be further improved in study could bring some biases. A double blind study terms of number of sessions, items of discussions, role of should be recommended. the family and the patients in the process in order to better maintain the positive outcomes and the parameters that This study has several strengths. It evaluates the efficacy of have not improved. psychoeducation in the real clinical practice following a multicenter design and it analyses not only the clinical 4.3 Methodological issues parameters, the relationship and the quality of life as dif- This study has some limitations. It is a cross-sectional ferent parameters, but it also focuses on how the improve- study and cohort effect can distort the results. The number ment of compliance can lead to a reduction of relapse, as of the patients in small, so larger studies is needed to con- it is shown in international literature. firm this data. This bias could be reduced comparing the data with an international meta-analysis. 5. Conclusion A number of studies have show that a psychoeducational Though the staff carrying out psychoeducation and stand- intervention with schizophrenic patients and their fami- ard psychosocial intervention and the staff administering lies, could reduce the occurrence of relapse [2,55-58]. Such decrease seems to be related with a decrease in hos- pitalizations, with less sick days on the job, and with less social expenses [59-61]. S Figure 7 ANS scale, group of items ROMI sca Figure 9 le: reasons for non participating SANS scale, group of items. ROMI scale: reasons for non participating. Page 9 of 12 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2007, 3:7 http://www.cpementalhealth.com/content/3/1/7 Nu Figure 12 mber of Hospitalizations S Figure 10 impson-Angus scale Number of Hospitalizations. Simpson-Angus scale. associated with hospitalizations, loss of working days, The study is part of an international program whose effort tension, family and social apprehensions. is to assess the effectiveness of a psychoeducational treat- ment in the prevention of relapses, through a change in In conclusion, such multicentric experience allows us to the understanding and the acceptance of the disorder. Our confirm that the psychoeducational approach has con- study confirms improvements on most clinical parame- tributed significantly to an integrated approach that put ters, quality of life, adherence to the treatment program, together patients active role in managing symptoms, fam- reduction of relapse and number of hospitalisation. ily members participation and psychiatric staff work that led to a global improvement and a reduction of relapses A psychoeducational therapeutic approach always seems and hospitalizations. to have positive effects on both the patients and their fam- ily. In fact, results show that even short term educational- The result is an undoubtedly great advantage for the informative contents were able to improve the patients' patients, who becomes an active participant in their ther- level of compliance to the treatment program, the apeutic process, experiencing not only an improvement patients' and their family members' attitude toward the from a clinical stand point, but also an overall increased disorder, and their attitude toward the psychiatric staff. psychological wellness, reducing significantly the troubles Also, such educational approach seem to be able to and the bad feelings caused by such afflicting disorder. improve the individuals' perception of quality of life, which represents an indirect tool used to reduce self and hetero-stigmatization. The participation of family mem- bers in the study has allowed a more effective manage- ment of the patient and a better implementation of a psychosocial rehabilitation process. 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Dyck DG, Hendryx MS, Short RA, Voss WD, McFarlane WR: Serv- ice use among patients with schizophrenia in psychoeduca- tional multiple-family group treatment. Psychiatric Services 2002, 53(6):749-754. 60. Herz MI, Lambert JS, Mintz J, Scott R, O'Dell SP, McCartan L, Nix G: A program for relapse prevention in schizophrenia: a con- trolled study. Archives of General Psychiatry 2000, 57(3):277-83. Publish with Bio Med Central and every 61. Hahlweg K, Wiedemann G: Principles and results of family ther- scientist can read your work free of charge apy in schizophrenia. Eur Arch Psychiatry Clin Neurosci 1999, 249(Suppl 4):108-115. "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." 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