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Table of Contents
CONCEPT ARTICLE
Year : 2014  |  Volume : 8  |  Issue : 1  |  Page : 46-52

Psychoeducation for mental illness: A systematic review


1 Nurse, Dept of Nursing, NIMHANS, Bangalore, India
2 Incharge Nurse, Dept of NIMHANS, Bangalore, India
3 Additional Professor, Dept. of Psychiatry, NIMHANS, Bangalore, India

Date of Web Publication8-Jul-2019

Correspondence Address:
B M Suresh
Additional Professor, Dept. of Psychiatry, NIMHANS, Bangalore
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-1505.262279

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  Abstract 


Psychoeducation is a specific form of education. It is aimed at helping persons with a mental illness or anyone with an interest in mental illness, to access the facts about a broad range of mental illnesses in a clear and concise manner.[1] Teaching patients and families with a view to improving treatment compliance is a major goal in psychiatric nursing [2] and client adherence to treatment regimen increases when health education is an integral part of the client’s care [3]. The aim of this review was to determine whether the importance and advantages of psychoeducation is and whether it is supported by evidence of effectiveness from rigorous clinical trial researches. Database literature searches were performed in a pre-defined manner. Thirteen RCTs were located, that investigated about psychoeducation and mental disorders. The evidence are supportive of benefits of psychoeducation in combination with usual treatment except only in very few trials suffering from significant methodological flaws. There is evidence to suggest that benefit of psychoeducation is significant for patient suffering from major mental disorder such as schizophrenia and mood disorder and short term psychoeducation is beneficial in personality disorder.


How to cite this article:
Shindhe SS, Kusuma N, Nagarajaiah, Suresh B M. Psychoeducation for mental illness: A systematic review. Indian J Psy Nsg 2014;8:46-52

How to cite this URL:
Shindhe SS, Kusuma N, Nagarajaiah, Suresh B M. Psychoeducation for mental illness: A systematic review. Indian J Psy Nsg [serial online] 2014 [cited 2022 Jul 3];8:46-52. Available from: https://www.ijpn.in/text.asp?2014/8/1/46/262279




  Introduction Top


The concept of psychoeducation was first noted in the medical literature, in an article by John E. Donley “‘Psychotherapy and re-education” in The Journal of Abnormal Psychology, published in 1911. It wasn’t until 30 years later that the first use of the word psychoeducation appeared in the medical literature in title of the book “The psycho-educational clinic” by Brian E. Tomlinson. New York, NY, US: MacMillan Co. This book was published in 1941. The popularization and development of the term psychoeducation into its current form is widely attributed to the American researcher C.M. Anderson in 1980 in the context of the treatment of schizophrenia.[4]

What is Psychoeducation?

Psychoeducation is defined as the education of a person with psychiatric disorder in subject areas that serve the goals of treatment and rehabilitation. The terms ‘patient education’, and ‘patient instruction’ have also been used for this process. All imply that there is a focus on knowledge.[1]


  Purpose of Psychoeducation Top


  • Enable the patient to engage in behaviour change.
  • To prevent hospitalization or to manage the illness or condition to help the patient attain her/his maximum degree of health.
  • Compliance with treatment for seriously or persistently mentally ill people is of great concern and is often a focus of patient education
  • To enhance family coping and to bring down disease burden [2]



  Methods Top


Computerized literature searches were performed on the Pubmed, Medline, CINAHL and Cochrane Library databases to locate all articles on psychoeducation. The search terms used were psychoeducation, mental illness, schizophrenia, mood disorder and depression and personality disorder, the reference lists of articles were checked for further relevant publications. The articles were read in full and data extracted in a standard pre-defined manner by the first author. Only articles relating to randomized controlled trials (RCTs) published literature are discussed. The quality of these trials was assessed using the Jadad quality scoring system. The Jadad system awards up to 5 points for randomization, blinding and description of dropouts.


  Results Top


Thirteen RCTs were located that investigated psychoeducation and mental disorders: chronic mental disorder (1), schizophrenia (6), Bipolar affective disorder (2), Depression (2), Personality Disorder (2).




  Discussion Top


A general problem in assessing the efficacy of psychoeducational interventions for people with mental disorder is the scarcity of data. In this review only thirteen small studies could be included. Poor reporting of data compounds the problem. Both interventions and outcomes were heterogeneous even in the included studies, psychoeducational programmes were given many names (programme for relapse prevention, family education, psychoeducational workshop, etc) but all these approaches did include similar contents.

Psychoeducation and schizophrenia

First episodes of schizophrenic disorder represent a fully new and incomprehensible experience. The emerging symptoms, including hearing voices, delusional perception, thought insertion, disorganized thinking etc, are all completely unfamiliar. Accordingly, most patients and relatives react with helplessness and in an uncoordinated manner. Psycho education entails teaching those affected the “ABC” of schizophrenic disorders and their treatment, however, a large number of individual facts which, despite individual differences, are generalizable and applicable to the majority of patients. On account of this, it is imperative for the sake of economy that such fundamental information is passed on as quickly as possible within groups

Sun-Kyung Shin designed a RCT to evaluate the Effects of Psychoeducation for Korean Americans with Chronic Mental Illness. Forty-eight Korean-American adults with a diagnosis of schizophrenia were randomly allocated to either an experimental group that provided a culturally sensitive psychoeducational group program in addition to individual supportive therapy or a control group that offered only individual supportive therapy. The experimental treatment included ten weekly psychoeducational group sessions as well as weekly individual supportive sessions. Each of three psychoeducational groups included eight participants. Members of the control group received only the ten individual supportive sessions. The two groups were compared on pre- and post treatment measures of psychiatric symptoms, attitudes about and understanding of mental illness, and coping skills to avail expected outcome. The experimental psychoeducational treatment group has shown significantly reduced symptom severity, greater understanding of mental illness leading to a decreased perception of stigma, and greater coping skills after the intervention than the control group. Hence it is important that culturally sensitive psychoeducational intervention is a useful short-term treatment modality for patients with chronic mental disorder and also helps in preventing relapses, facilitating rehabilitation, and promoting community mental health. Hence current best practices suggest that some form of education for the person with the illness and for the family is a critical component of effective treatment.[17]

A RCT sought to evaluate the influence of Psychoeducational intervention and prevention of relapse among schizophrenic disorders. 150 patients with schizophrenia over 15 centers in Italy were recruited for the study, half of the patients affected by schizophrenia underwent a traditional drug treatment (the control group), while the second half of the sample underwent a treatment, along with the traditional psychosocial interventions, a psychoeducational treatment over 1 year. The scales assessment was carried out at the beginning of the trial, after 6 months and 12 months. At the end of the study the parameters “Number of hospitalizations” and “Total number of hospital days” were checked. Each time drug recording and vital parameters were assessed. 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). Significance was in the reduction of relapse in terms of numbers of hospitalization, days of hospital stay and clinical parameters. The study reveals that psycho educational approach has contributed significantly to an integrated approach that put together patient’s active role in managing symptoms, family member’s participation and psychiatric staff work that led to a global improvement and a reduction of relapses and hospitalizations. Hence importance to psycho education to be laid down and it can be used as add-on treatment in conjunction with other treatment.[10]

Similarly the studies mentioned in the review have shown that significant improvement happens with psychoeducation when it is used as an add-on treatment along with traditional treatment.

Psychoeducation and mood disorder

The increasing evidence of the efficacy of the pharmacologic treatment of bipolar disorders has sometimes led clinicians and mental health professionals to forget psychological interventions as an adjunctive treatment. Other possible reasons for this negligence are the several methodological pitfalls present in most of the studies on psychological interventions in bipolar disorders. The psychoeducative approach has been performed by many clinicians for decades, but the first studies on its efficacy did not appear until recent years. To date, only the study of Perry and colleagues on individual psychoeducation included a control group, singleblind design, and provided results on efficacy measured as a decrease in the number of recurrences.[16]

This paper is a report of efficacy of two internet interventions for community-dwelling individuals with symptoms of depression. The internet intervention is a psychoeducation website offering information about depression and an interactive website offering cognitive behaviour therapy. 525 individuals with increased depressive symptoms recruited by survey and randomly allocated to a website offering information about depression (n = 166) or a cognitive behaviour therapy website (n = 182), or a control intervention using an attention placebo (n = 178). Change in depression, dysfunctional thoughts; knowledge of medical, psychological, and lifestyle treatments; and knowledge of cognitive behaviour therapy were used to measure the outcome. The study shown that information about depression and interventions that used cognitive behaviour therapy and were delivered via the internet were more effective than a credible control intervention in reducing symptoms of depression in a community sample. For the intervention that delivered cognitive behaviour therapy the reduction in score on the depression scale of the Center for Epidemiologic Studies was 3.2. For the “depression literacy” site (BluePages), the reduction was 3 and it significantly improved participants’ understanding of effective evidence based treatments for depression (P < 0.05). Hence the study concluded that cognitive behaviour therapy and psychoeducation delivered via the internet are effective in reducing symptoms of depression.[13]

This study evaluated the effectiveness of a pilot psychoeducational program in improving mood and social functioning for clients with Bipolar mood disorder. Twenty-one participants were recruited for this pilot study living in the community. The study participants attended 15-week group and were educated about Bipolar mood disorder, triggers for mood relapse, and coping strategies. Pre- and post-group inventories measured depressive and manic symptoms, as well as social functioning. Following the group, significant improvements were seen in self-reported symptoms of depression and anxiety. Decreases in self-reported social functioning and clinician-rated symptoms of depression and mania were non-significant. The preliminary findings of the study suggest that psychoeducational intervention is helpful in decreasing depressive and anxious symptoms hence psychoeducation when used adjunctively with medication, it is to decrease manic and depressive relapses.[6]

A controlled, randomized study has been conducted to evaluate the Efficacy of Group Psychoeducation in the Prophylaxis of Recurrences in Bipolar Patients Whose Disease Is in Remission indicate that some interventions may reduce the number of recurrences in bipolar patients. One hundred twenty bipolar I and II outpatients in remission for at least 6 months prior to inclusion in the study, who were receiving standard pharmacologic treatment, were included in a controlled trial. Subjects were matched for age and sex and randomized to receive, in addition to standard psychiatric care, 21 sessions of group psychoeducation or 21 sessions of nonstructured group meetings were given. Subjects were assessed monthly during the 21-week treatment period and throughout the 2-year follow-up the results of the study shown Group psychoeducation significantly reduced the number of relapsed patients and the number of recurrences per patient, and increased the time to depressive, manic, hypomanic, and mixed recurrences. The number and length of hospitalizations per patient were also lower in patients who received psychoeducation. The study suggested that Group psychoeducation is an efficacious intervention to prevent recurrence in pharmacologically treated patients with bipolar I and II disorder.[16]

Psychoeducation and personality disorder

A RCT sought to evaluate whether being taught the latest information concerning borderline personality disorder (BPD) leads to a decline in core BPD symptoms and an improvement in psychosocial functioning of patient suffering from BPD. 50 subjects were recruited for study who met criteria for BPD. Then 30 were randomized to a psychoeducation workshop that took place within a week of diagnostic disclosure. The other 20 were assigned to a waitlist and participated in the workshop at the end of this 12-week study. The two primary outcome measures were readministered each week of the trial: the Zanarini Rating Scale for DSM-IV Borderline Personality Disorder (ZAN-BPD) and the Sheehan Disability

Scale (SDS). Immediate psychoeducation concerning the BPD diagnosis was associated with a significantly greater decline in general impulsivity and the storminess of close relationships. However, it did not result in significantly improved psychosocial functioning. The results of this study suggest that informing patients about BPD soon after diagnostic disclosure may help to alleviate the severity of two of the core elements of borderline psychopathology—general impulsivity and unstable relationships.[8]

A randomized controlled trial study is conducted in East Midlands region of England, encompassing four counties and a mix of urban and rural setting to determine the effectiveness of a problem-solving intervention for adults with personality disorder in the community under conditions resembling routine clinical practice. 126 Participants were recruited for study and equal number of subjects distributed randomly to brief psychoeducation plus16 problem-solving group sessions and to waiting-list control. The expected primary outcomes were comparison of scores on the Social Problem Solving Inventory and the Social Functioning Questionnaire between intervention and control arms at the conclusion of treatment, on average at 24weeks after randomisation. The results of study shown that, those allocated to intervention showed significantly better problem-solving skills (P50.001), higher overall social functioning and lower anger expression compared with controls. No significant differences were found on use of services during the intervention period. The study concluded that problem-solving plus psychoeducation has potential as a preliminary intervention for adults with personality disorder. These results are a useful beginning and further carefully constructed randomised controlled trials are now required to confirm these initial encouraging results [9]

A range of psychoeducative Therapy is being used for various psychiatric disorders. In this systematic review, Thirteen RCTs were located that investigated psychoeducation and mental disorders: chronic mental disorder (1), schizophrenia (6), Bipolar affective disorder (2), Depression (2), Personality Disorder (2). These facts render rigorously controlled trials essential for evaluating effectiveness of psychoeducation for mental disorders. Many trails revealed that most of the psychiatric illness such as schizophrenia, mood disorder, and personality disorder benefited with cost effective add-on psychoeducation and extensively brought down the recurrence and relapse of illness and significantly contributed to the reduction in family burden and stigma attached to it and enhanced drug compliance.

The possibility of publication bias must be considered, as there are very minimal controlled Indian studies found in the above search database. In addition, it is important to remember that there are potential sources of bias in the selection of eligible patients in such clinical trials. Some of the trials located in the literature suffer from small sample size as well as other methodological flaws as indicated by their Jadad scores. More well-designed, conducted and reported randomised studies investigating the efficacy of psychoeducation are needed. Any future trials should employ well standardized psychoeducational programmes with clear definitions of the content of interventions to help professionals planning evidence based psychoeducational interventions, people with mental illness and family members participating in psychoeducation programmes. Not only should compliance, relapse and readmission be recorded as outcomes, but also psychosocial function, quality of life and insight. Health economic outcomes should also be measured, as the efficiency of psychoeducation is crucial in making it an attractive option for policy makers. Further research is also needed into the efficacy of different formats of psychoeducational interventions.


  Conclusion Top


Evidence from trials suggests that psychoeducational approaches are useful as a part of the treatment programme for people with schizophrenia and related illness. The fact that the interventions are brief and cost effective should make them attractive to managers and policy makers. More well-designed, conducted and reported randomised studies investigating the efficacy of psychoeducation are needed. In conclusion, rigorous clinical trial research on the psychoeducation on various psychiatric disorders is scarce in India. All require further investigation in large-scale RCTs..

This is a serious concern over the psychoeducation for mental illness in India. As a Psychiatric Mental Health Nurse we have to take an initiation to overcome this issue.



 
  References Top

1.
The Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD002831. DOI: 10.1002/14651858.CD002831. Available from: URL: http://digilib.bc.edu/reserves/nu426/shin/ nu42611.pdf  Back to cited text no. 1
    
2.
Antai-Otong D. Concerns of the hospitalized and community psychiatric client. Nursing Clinics of North America 1989; 24:665{73.  Back to cited text no. 2
    
3.
American Nurses Association. A statement on psychiatric-mental health nursing practice and standards of psychiatric-mental health clinical nursing practice. Washington DC: The Association,1982  Back to cited text no. 3
    
4.
Psychoeducation. Available from: URL: http://en.wikipedia.org/wiki/Psychoeducation  Back to cited text no. 4
    
5.
Kae Shimazu, et al. Family psychoeducation for major depression: randomised controlled trial. BJP May 2011 198:338-340; doi:10.1192/bjp.bp.110.090209  Back to cited text no. 5
    
6.
Rebecca Bassili, et al. Pilot Evaluation of a Psychoeducational Group for People with Bipolar Disorder. Queens health science Journal 2009, Vol 9, No2, 12-16  Back to cited text no. 6
    
7.
Tanveer Nasr and Rukhsana Kausar. Psychoeducation and the family burden in schizophrenia: a randomized controlled trial. Annals of General Psychiatry 2009, 8:17. Available from: URL: http://www.annals-general-psychiatry.com/content/8/1/17  Back to cited text no. 7
    
8.
Mary C. Zanarin and Frances R. Frankenburg. A Preliminary, Randomized Trial of Psychoeducation for Women With Borderline Personality Disorder. J Pers Disord. 2008 Jun; 22(3):284-90.  Back to cited text no. 8
    
9.
Nick huband, Mary McMurran, Chris Evans and Conor Duggan. Social problem-solving plus psychoeducation for adults with personality disorder Pragmatic randomised controlled trial. British Journal of Psychiatry, 2 0 0 7, 1 9 0, 3 0 7 -313.  Back to cited text no. 9
    
10.
Eugenio Aguglia, Elisabetta Pascolo-Fabrici, Francesca Bertossi and Mariano Bassi Psychoeducational intervention and prevention of relapse among schizophrenic disorders in the Italian community psychiatric network. Clinical Practice and Epidemiology in Mental Health 2007, 3:7doi:10.1186/1745-0179-3-7. Available from: URL: http://www.cpementalhealth.com/content/ 3/1 /7  Back to cited text no. 10
    
11.
Gabriele Pitschel-Walz, Josef Bäuml, Wolfram Bender, Rolf R. Engel, Michael Wagner, and Werner Kissling, Psychoeducation and Compliance in the Treatment of Schizophrenia: Results of the Munich Psychosis Information Project Study. J Clin Psychiatry 2006;67:443-452  Back to cited text no. 11
    
12.
Lai-Yu Cheng and Sally Chan. Psychoeducation program for Chinese family carers of members with schizophrenia. Western journal of nursing research. 2005, vol 27, no 5, 583-599  Back to cited text no. 12
    
13.
Helen Christensen, Kathleen M Griffiths, and Anthony F Jorm. Delivering interventions for depression by using the internet: randomized controlled trial. BMJ 2004;328doi: 10.1136/bmj.37945.566632.EE  Back to cited text no. 13
    
14.
Bechdolf A, et al. A randomized comparison of group cognitive-behavioural therapy and group psychoeducation in patients with schizophrenia. Acta Psychiatr Scand. 2004 Jul; 110(1):21-8.  Back to cited text no. 14
    
15.
Mao-Sheng, et.al. Effectiveness of psychoeducational intervention for rural Chinese families experiencing schizophrenia: A randomized controlled trial. Soc Psychiatry Psychiatr Epidemiol (2003) 38 : 69 –75  Back to cited text no. 15
    
16.
Francesco Colom. A Randomized Trial on the Efficacy of Group Psychoeducation in the Prophylaxis of Recurrences in Bipolar Patients Who’s Disease Is in Remission. Arch Gen Psychiatr.2003, vol 60, 402-407  Back to cited text no. 16
    
17.
Sun-Kyung Shin, M.S.W. and Ellen P. Lukens. Effects of Psycho education for Korean Americans with Chronic Mental Illness. Psychiatric Services. September 2002 Vol. 53 No. 9, 1125-1131  Back to cited text no. 17
    




 

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Introduction
Purpose of Psych...
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