Meta-Review of Systematic and Meta-Analytic Reviews on Family Psychoeducation for Schizophrenia

  

    
 
    
Dixon 
      
(1995) 
    
Penn 
      
(2001) 
    
Pitschel-Walz    (2001) 
    
Pekkala (2002) 
    
Pilling 
      
(2002) 
    
Zygmunt (2002) 
    
Pharoah  (2006) 
    
Lincoln (2007) 
    
Xia (2011) 
  
  

    
1. Was an 'a priori' design provided?
    
YES
    
YES
    
YES
    
YES
    
YES
    
YES
    
YES
    
YES
    
YES
  
  

    
2. Was there duplicate study selection and    data extraction?
    
YES
    
NO
    
YES
    
YES
    
YES
    
YES
    
YES
    
YES
    
YES
  
  

    
3. Was a comprehensive literature search performed?
    
YES
    
NO
    
NO
    
YES
    
YES
    
YES
    
NO 
    
YES
    
NO
  
  

    
4. Was the status of publication (i.e. grey    literature) used as an inclusion criterion?
    
YES
    
NO
    
YES
    
Cannot answer
      
 
    
YES
    
YES
    
Cannot answer
      
 
    
YES
    
Cannot answer
      
 
  
  

    
5. Was a list of studies (included and excluded) provided?
    
YES
    
NO
    
NO
    
YES
    
YES
    
NO
    
YES
    
NO
    
YES
  
  

    
6. Were the characteristics of the included studies provided? 
    
YES
    
YES
    
YES
    
YES
    
YES
    
YES
    
YES
    
YES
    
YES
  
  

    
7. Was the scientific quality of the included studies assessed and    documented?
    
YES
    
Cannot answer
    
YES
    
YES
    
YES
    
YES
    
YES
    
YES
    
YES
  
  

    
8. Was the scientific quality of the included studies used    appropriately in formulating conclusions?
    
YES
    
YES
    
YES
    
YES
    
YES
    
YES
    
YES
    
YES
    
YES
  
  

    
9. Were the methods used to combine the findings of studies    appropriate?
    
NO
    
Cannot answer
    
YES
    
YES
    
YES
    
NO
    
YES
    
YES
    
YES
  
  

    
10. Was the likelihood of publication bias assessed?
    
NO
    
NO
    
YES
    
YES
    
YES
    
NO
    
YES
    
YES
    
YES
  
  

    
11. Was the conflict of interest stated?
    
NO
    
NO
    
Cannot answer 
    
YES
    
Cannot answer 
    
YES
    
YES
    
YES
    
YES
  
  

    
Tot YES
    
8/11
      
(72%)
    
3/11
      
(27%)
    
8/11
      
(72%) 
    
10/11
      
(91%)
    
10/11
      
(91%) 
    
8/11
      
(72%)
    
9/11
      
(81%)
    
10/11
      
(91%)
    
9/11
      
(81%)
  
  

    
Taylor (2009) Quality Assessment
    
 
    
 
    
12/14
      
(85%)
    
14/14
      
(100%)
    
14/14
      
(100%) 
    
 
    
14/14
      
(100%)
    
 
    
 
  

Table 4: AMSTAR evaluation.

For comparison, we also reported the quality rating concerning the four systematic reviews or meta-analyses on family psychoeducation covered in the Taylor, et al. 2009 meta-review on institutional care for people with long-term mental health problems [26].

In our scoring, one review only obtained a score below 50% of maximum score. Five out of nine included reviews scored above 80% of the maximum score, indicating good quality of the review. The scoring of the reviews also covered in the Taylor, et al. 2009 meta-review was similar to the present scoring, thus supporting the reliability of the judgment[26].

Evidence of relapse: Relapse as an outcome was covered in eight reviews out of nine, but collapsed the information with that on rehospitalization [12,14]. Risk of relapse was reported to be reduced in protocols that included family members, but not in interventions focussing on patients only. Family psychoeducation was reported to be effective whether conducted in single family or in multifamily group sessions [13]. Effectiveness seems not to be maintained at follow-up [27,28]. When relapse was considered together with re-hospitalization as an outcome, some evidence in favour of maintenance of effectiveness at follow-up was reported [12,14].

Evidence of hospital admission/re-hospitalization: Evidence of hospital admission/re-hospitalization was covered in four reviews out of nine. No evidence of a decrease of hospital admission/rehospitalization was reported in three reviews out of four. Xia, et al. 2011 reported a reduction of the risk of relapse with readmission in the long term (RR = 0.71 [0.56, 0.89])[14].

Evidence of compliance/medication adherence: Compliance/ medication adherence was covered in three reviews out of nine. Two reviews found no effectiveness of family psychoeducation on compliance/medication adherence. Xia, et al. 2011 reported an improvement in the short, medium and long term, drawing evidence from ten, six and three independent studies, respectively [14]. The effects in the longterm were appreciable but with a wide(>0.25) confidence interval (RR= 0.48[0.31-0.75]).

Overall quality of evidence: Overall, quality of evidence on the effectiveness of family psychoeducation in schizophrenia is poor. There was limited overlap between the reviews of the included studies. It is therefore difficult to compare the findings of one review with another. The AMSTAR score was reasonably good for most reviews, but the risk of bias of the included studies was estimated in six reviews only.

In some reviews it was not clear whether RCTs only were included; in some reviews qualitatively different outcomes (e.g., relapse and re-hospitalization) were collapsed to produce an overall estimate of effectiveness. Most findings were doomed by imprecision (wide confidence intervals), or derived by less than 10 independent trials, which limits estimation of heterogeneity and bias in publication. Magnitude of effect, when present, was in the medium-to-low effect size, no dose-response could be established, and confounders were not properly addressed.

Our evaluation agrees with that reported by Xia, et al. 2011 in their reviews, in which they judged the available evidence on the effectiveness of family psychoeducation to be low to very low [14].

Discussion

We reviewed the available evidence on the effectiveness of family psychoeducation in schizophrenia. Systematic reviews and metaanalyses only were considered, since they are expected to convey the highest level of evidence in describing the strength of the results measured in a clinical trial or research study. Quality of evidence was assessed by both considering the adherence of each review to the current standard of review methodology, and taking into account studies’ findings andthe degree of confidence in their estimates.

We found that in the shortterm (at post treatment or shortly after) family psychoeducation was related to a consistent reduction of relapse into acute psychosis. The effect was mainly produced by protocols that included family members in the session, whether applied to a single family or to a multifamily group. This result did not translate into a consistent reduction of hospital admission/re-hospitalization over the medium/long-term and was not stable at follow-up. No evidence was found of an effect of family psychoeducation on compliance or medication adherence.

As already noted by Lincoln, et al. 2007, the heterogeneity of studies and the low numbers for most outcome categories produced effects with large confidence intervals, which hampers confidence on these estimates [12]. Overall, the low quality score that can be attributed to the grade of current evidence on the effectiveness of family psychoeducation suggests that further research is very likely to change both these estimates and the confidence that can be assigned to them.

Scarce or null effect on medication adherence discounts one of the explanations that were advanced to explain potential effectiveness of family psychoeducation, which was suggested to reduce relapse by increasing adherence to therapies. Alternative explanations on the effectiveness of psychoeducation purport a positive influence on family climate, by a lenient impact on expressed emotion [29], and improved problem-solving and coping skills in the patients and their relatives in the face of new psychopathological crises [10]. Whether one of these explanations or both are grounded is still undetermined.

Poor maintenance of the effects in the medium/long-term follow-up suggests that family psychoeducation does not translate into a stable change in family functioning. It can be advanced that family psychoeducation works as a form of supportive intervention, enabling families facing difficult situations to cope with them and receive emotional and practical support. Alternatively, it can be hypothesized that family psychoeducation produces adaptations that work in the current situation but do not generalize to new types of crisis. Either way, family psychoeducation would be effective when provided on a recurrent basis, without any expectation of any magical effects beyond its administration. Patients that discontinue drugs have a hugely enhanced risk of relapse into active psychosis [30]. Some psychosocial interventions should similarly require continuous administration to provide benefit. In planning such kind of interventions, costs of administration in terms of staff, time and location should be weighed against savings following reduction of relapse and, possibly, of re-hospitalization.

In the wake of the current financial cuts in the healthcare sector, it is encouraging that multifamily groups have a comparable effectiveness to single-family interventions. Preliminary evidence suggests that brief psychoeducational interventions-expected to be less expensive in terms of time and staff-can reduce relapse in the medium term when provided to people with severe mental illness, and favor medication compliance in the short term [31]. It is not clear how this evidence can generalize to family psychoeducation applied to people with schizophrenia, since quality of evidence was rated low [31].

It is worth mentioning that multimodal protocols of care addressing first-episode psychosis within the framework of the “early intervention” paradigm were able to produce measurable effects in the short term, which also translated into considerable cost curbing following lower hospitalization rates [32,33]. These positive effects tend to disappear after termination of the intervention [34,35].

Early intervention services usually include individual and family psychoeducation, cognitive behavioral therapy, and a wide range of both structured and unstructured psychosocial interventions (i.e., skills training group, school and professional training). These interventions are likely to contribute the most in the short term to the superiority of these protocols of care over treatment as usual (TAU). When these interventions cease, and pharmacotherapy remains the principal tool to treat patients with chronic schizophrenia, differences with TAU disappear [34].

An unexpected finding of this meta-review is the scarce overlap of primary studies among the reviews. It appears that different authors promote different criteria to include a study into a systematic review or a meta-analysis. When more stringent criteria are applied, evidence of the effectiveness of family psychoeducation for schizophrenia is attenuated in a range of outcomes [14]. The appraisal of these differences across reviews is important for stakeholders, particularly in long-term organizational decisions, such as those that derive from the inclusion of a recommendation in guidelines. Future systematic reviews are expected to be transparent in the definition of inclusion and exclusion criteria of the studies to be reviewed.

Conclusion

Narrative reviews are greatly more optimistic on the real effectiveness of family psychoeducation interventions [16], and on the basis of these optimistic reviews family psychoeducation is recommended as evidence-based practice in several guidelines for schizophrenia or severe mental illness [36-38]. The evidence drawn from meta-analyses is more conservative, and so far effects have been reported in the moderate-to-small range for risk of relapse [12,14], with small effects on psychosocial functioning [39]. It must be stressed that the expression “family psychoeducation” covers several approaches, which differ in their theoretical orientation, modality, and duration [39]. Conflating different models to the aim of quantitative analysis might obscure relevant aspects of the single intervention.

As a matter of fact, patients with psychosis often live in close contact with their relatives, who give them informal care and support. High levels of family burden and family stress (i.e., expressed emotion) result from the impact of the disorder on close relatives [29]. Despite this, the provision of family interventions is limited [40].

The results of this meta-review indicate the necessity of further studies on the effectiveness of family psychoeducation, to address inconsistencies in the literature and identify specific processes involved in the efficacy of the intervention (impact on family climate versus improved coping, and problem-solving versus promotion of adherence to pharmacotherapy) [41].

Acknowledgment

This study is supported by the Italian Medicines Agency (Agenzia Italia del Farmaco) – grant for SPERA-S Study on Psychoeducation Enhancing Results of Adherence in Schizophrenia (FARM892ZXE). DRP is the principal investigator and grant holder of the SPERA-S study and is - together with CM - speaker of the SPERA-S research network. DRP, AP, CM, CZ, CL, IP, PP all contributed to the design of the study. DRP, CL and AP contributed to the study with qualitative data analysis. DRP, AP, CM, CZ, CL, IP, PP drafted the paper. All the authors have revised the paper and have approved the final manuscript. Dr C. L. is the recipient of a Grant from the Regione Sardegna, Italy (Grant n. PRR-MAB-A2011-19250, “Programma Master & Back 2010/2011 - Percorsi di Rientro). DRP, CM, AP design the study.

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