FAMILY PSYCHOEDUCATION & CARE of the Schizophrenic Client

Present by: Sandra Brewry Rn. Cert. psy. Kacyon Carroll Rn. Antionette Duff Rn. Andrea Johnson Rn. Beulah Wilson-Williams Rn. Cert. psy. Cert mngt. Horace Williams Rn. Cert. psy.

An EVIDENCE BASED PRACTICE PRESENTATION

Clinical issue that we would like to see changed

Increased admission rates for schizophrenic patients between the ages of 25-35 years old.

Factors that would influence the outcome

Assessment
Combination treatment modalities

Family involvement
Follow up care

Formulation of PICOT question to drive our search

P- Increased admission rates for schizophrenic
patients 25-35 years old

I- Family psychoeducation in the management

of all schizophrenic patients 25-35 years old

C- Pharmacotherapy only O- Reduction of readmission rates for patients in

the 25-35 years age group

T- Over a six month period.

Question under search

How does family psychoeducation in the management of schizophrenic clients in the age group 25-35 years when compared to pharmacotherapy only, affect readmission rates over a six month period?

EVIDENCE SEARCH/SEARCH STRATEGY

Evidence search was done using electronic

data bases Ebsco Host, Pubmed, Medline, Schizophrenia Research, Psycho line, EMBASE, Psyclit and Medscape.

 Articles written in English and covering the period (1982-2011) were used in the search. Psychoeducation, Family psychoeducation, Pharmacotherapy, Family and readmission rates for schizophrenics, Family management and its effect on the mentally ill, a family approach to schizophrenia management were used as search terms.

Definition of Family Psychoeducation

According to the Encyclopaedia of Mental Disorder (2011), Family psychoeducation is defined as a method based on clinical findings for training families to work together with mental health professionals as part of an overall clinical treatment plan for their family members, these include programmes that provide families with information about mental illness, its symptoms and treatment.

Definition of Schizophrenia
Schizophrenia is a serious psychotic

condition characterized by impaired thoughts, ( including delusions & altered perception) communication/interpersonal relationships and an inability to perform activities of daily living. (Frisch & Frisch, 2007).

 Limitations on the search were, over a six

month period, Clinical journals, in the age group 25-35 years and over a six month period. A total of (150) journals covering a period of 26 years (1985-2011) were looked at because they had some relationship to the search terms entered and the general question under search.

 Four (4) were kept as they were relevant and

had a direct relationship to the question under search; these articles met the inclusion criteria since they were studies that looked at family involvement and their effect on admission rates, were written in English and published in journals during the search span.

 The next step was to exclude articles that

didnt meet the search criteria by simply looking at their abstract. Family involvement in the management of schizophrenic and reduction in admission rates were also used as key terms.

 Three of the four questions kept were meta-

analyses; these were kept since metaanalyses are the gold standard (level I in the strata of quality of evidence in Evidence Based Practice (EBP)) in evaluating the efficacy of clinical interventions (Le Lorier et al, 1997).

 A Meta-analysis is a quantitative technique

for combining the results from several clinical trials to provide an objective overview of their conclusions, usually in the form of one or more global measures (Melnyk et al, 2006).

 The other was a Randomized Clinical Trial

(RCT). A RCT compares the effectiveness of different treatments to determine which is better and may have a control arm and an intervention arm and ranks as level II evidence in terms of quality (Melnyk et al, 2006).

 In keeping with the issue identified by the

group we thought that the articles reviewed below are directly related and will answer questions with regards to reducing readmission/admission rates in schizophrenic clients at Health care facilities in Jamaica.

EVIDENCE REVIEW/EFFECTIVENESS OF SEARCH

Topic of Search Article:
The Effect of Family Intervention on Relapse and

Rehospitalization in Schizophrenia-A Meta-analysis (Pitchel-Walz, et al 2011).

QUALITY OF EVIDENCE: Level I-Meta-analysis

 The main result from this meta-analysis showed that relapse rates can be reduced by 20 percent if relatives of schizophrenia patients are included in their treatment. The reviewers conclusions were that meta-analysis clearly confirmed the hypothesis that psychoeducational family interventions reduce relapse and rehospitalization rates of schizophrenic patients in relation to medication only.

Article II
Topic of the Article:
Psychological treatment in schizophrenia: 1. Meta-

analysis of family intervention and cognitive behaviour therapy (Pilling et al 2002).

QUALITY OF EVIDENCE: Level I-Meta-analysis

 The main results showed that interventions, in

particular single family therapy, had clear preventative eects on the outcomes of psychotic relapse and readmission and benefits in medication compliance. The reviewers conclusion stated that, despite questions about integrating family intervention into the clinical routine of health facilities and the long term effects, this meta-analysis confirmed the hypothesis that psychoeducational family interventions reduced relapse and readmission rates of schizophrenic patients in comparison to the use of medications alone.

Article III
Topic of Article:
Efficacy of Psychological Therapy in

Schizophrenia: Conclusions from Meta-analyses. (Pfammatter et al, 2006).

Quality of Evidence: Level 1-Meta-analysis

 The result proved that psychological approach to managing

schizophrenic clients yielded far more significant result than pharmacotherapy for one, pharmacotherapy commonly considered as cornerstone in the treatment of schizophreniahas limits. For example, relapse rates in schizophrenia remain substantial even when adherence to prescribed medication is monitored. The reviewers conclusions were that the present state of research provides sound evidence for the efficacy of psychological therapy (including family psychoeducation and participation in client care) in the treatment of schizophrenia.

Article IV
Topic of Article:
Family education for people with schizophrenia in

Beijing, China(Zheng, 2005).

QUALITY OF EVIDENCE: Level II- Randomised

Controlled Trial (RCT).

 The results suggested that the shorter the duration of

illness the less the families knew, but the more receptive they were to acquiring information, whereas longer duration of the patients illness gave relatives more time to formulate their own lay model of the illness, making them less likely to be influenced by professional opinions. The findings from this did help to prove the notion that medication adherence did not necessarily reduce deterioration in symptoms.

 Further, the education programme had a significant

effect on families knowledge, patient symptoms and overall functioning, particularly at 9 months after discharge as well as some reduction on relapse rate. Based on the findings from theses four studies, we can safely conclude, family psychoeducation positively affects readmission rates in schizophrenic clients, by reducing it.

SUMMARY of findings
To answer the burning clinical issue Increased admission rates for schizophrenic patients

between the ages 25-35 years old, we arranged it in PICOT format, How does family psychoeducation in the management of schizophrenic clients in the age group 25-35 years when compared to pharmacotherapy only, affect readmission rates over a six month period?

 Using various search engines, such as

Pubmed and Ebsco host, spanning a search period of 26 years (1985-2011) and using search terms such as psychoeducation, family psychoeducation, we looked for relevant literature to provide answers to our PICOT question.

 We looked at 150 pieces of literature and

identified three meta-analyses and one randomized control trial that were congruent and relevant with our topic.

 As was stated previously, a Meta-analysis is a quantitative technique for combining the results from several clinical trials to provide an objective overview of their conclusions, usually in the form of one or more global measures and a randomized control trial which compares the effectiveness of different treatments to determine which is better (Melnyk et al, 2006).

 According Le Lorier et al, (1997) meta-

analyses are the gold standard quality for evaluating the efficacy of a clinical intervention. Since we wanted the highest quality of evidence, we chose to use metaanalyses and one randomized control study, second on the table of hierarchy in terms of quality evidence.

 Despite unanswered questions which

related to the most efficient treatment setting, the differential indications of the various psychological interventions, identification of the specific therapeutic ingredients and a call to focus on the synergistic effects of combinations of psychological interventions with pharmacotherapy or psychosocial rehabilitation programs,

 conclusions can be drawn from the review

of these three four studies that showed there is a relatively large body of evidence to support the use of family psychoeducation as a "best practice" for young adults(25-35) with schizophrenia and their families.

 These suggestions are consistent with the work of researchers at the University of Maryland who posits that psychoeducation of the family is a compelling evidence in the management of schizophrenic clients in relation to medication alone, as it reduces readmissions, relapse rates and hospitalization. They further went on to say it should be offered to all families with relatives suffering from schizophrenia.

IMPLIMENTATION

THE DICENSO MODEL

Pilot study of a Patient at a well known psychiatric facility

A member of our group related to a Mr. J.D. a 33yrs old patient who was diagnosed with schizophrenia for the past five years (since 2006); His history stated he has been in and out of hospital for that time, in one particular year he was admitted to the institution on three separate occasions, despite being compliant with his medication regime.

 The family it would seem had low tolerance

levels; therefore as soon as J.D did anything they thought was abnormal they would take him back to hospital for admission. Given this, the group decided that we would use this client and his family members to test the effect that family psychoeducation would have on his treatment & relapse.

 Members of the health team were concerned

about the frequent admissions of J.D, especially given the new thrust of managing clients within their communities; we felt that J. D was utilizing valuable resources that could be used for other clients, since he had good family support.

 A member of this group suggested to the

health team that we were part of a group doing evidence based practice on a topic that covered family psychoeducation. Permission was granted for the group to implement its findings and by so doing assist the patient and his family.

 To implement the family psychoeducation

we decided to adopt the evidenced based decision making framework from DiCenso as cited by Melnyk (2006), which posited that Evidenced-based practice includes the following processes:

 Formulating a clinical question

Systematically searching for relevant

evidence Critically appraising the relevance, quality and applicability of the evidence.

 Making an evidence-based decision regarding implementation by considering the research evidence along with the practitioners clinical expertise, healthcare resources and the patient clinical status, circumstances, preferences and actions and depending on all the decision
Implementation of the practice change Evaluating the change in practice

 We began at step (IV) since we had already completed steps (I-III). The research evidence that we had, clearly showed that the use of family psychoeducation is a "best practice" for young adults (25-35) with schizophrenia and their families, which was defined as a method based on clinical findings for training families to work together with mental health professionals as part of an overall clinical treatment plan for their family members.

 These include programmes that provide

families with information about mental illness, its symptoms and treatment, medications and its side effects as well as how to communicate with persons with mental illness and techniques for crisis intervention and problem solving.

 The evidence at hand also stated that

hospital treatment of schizophrenia has increasingly been replaced by communitybased care since schizophrenic clients tend to function better in and around individuals with whom they are acquainted.

 Thus, more responsibility for managing the

burden of illness-related impairment should be passed on to patients and their relatives, who in turn would need to develop improved or adequate coping strategies. Therefore, consistent with these findings many experts in the field advocates a multimodal treatment approach for schizophrenia.

 The studies here, further added that of all

the psychological approaches, the family psychoeducation studies, which began has far back as the 70s, consistently demonstrated that schizophrenic patients with relatives taking part in their treatment, suffer from significantly fewer relapses and hospitalization during follow up.

 Next, we developed a multimodal approach (in keeping with our literature and our DiCenso, model) by assembling our team consisting of six clinically competent nurses (members of our group) the hospitals human resources and our evidence, which showed that family psychoeducation produced positive outcomes for both families and patients.

 We then looked at what the patient and

familys preferences and circumstances were, since they would prove to be the main stay in implementing this family psychoeducation.

 Optimally, patients and their families values

and preferences are based on careful consideration of information that provides an accurate assessment of the patients condition and possible treatments, as well as the likely benefits, costs and risks. Given this, we carefully assessed the client and family and determined that they would prefer Home all things (benefits, costs and risks) considered.

 In addition to looking at the patients and

familys preference, it required of us to make clinical decisions ( in conjunction with hospital resources, consisting of a consultant, a resident, intern, a pharmacist, psychiatric social worker

 psychologist and other expert psychiatric

nurses) in regards to the patients clinical state and circumstances. J.D was now clinically stable, lived in an area where he had easy access to psychiatric care and the family members had the resources to care for him outside of hospital

 We then looked at resources, financially the

hospital had no funding but had the human resources that we could draw on for expertise, which included the consultant, resident, pharmacist, psychiatric social worker, psychologist and other expert psychiatric nurses who were sufficient for this particular case, since the family could provide their own funding

 Armed with the evidence from our four

studies we were ready to implement the findings from our evidenced based search to the patient and his family.

 The first bit of our implementation plan was to utilize the multimodal approach, while keeping in mind the goal of family psychoeducation, which is to prevent patients with severe mental illnesses from relapsing, and to promote their re-entry into their home communities, with particular regard for their social and occupational functioning (Encyclopaedia of Mental Disorder, 2011).

 To achieve this goal, we sought to provide

the family with the information they needed regarding their relatives mental illness and the coping skills that would help them to deal with their loved one's psychiatric disorder, thus each member of the multimodal team played their part in education the family.

 The Doctor/Psychiatrist/Consultant-

met with the client and family members on atleast two occasions and had educational sessions about the clients diagnosis, its causes, risk factors, manifestations and the need for compliance to medication therapy as well as family support.

 The Psychologist- Had atleast four

sessions with the family members as together they sought to explore and identify various strategies for coping with the illness of their loved one, as well as attempting to bring to the fore any other situation that would cause stress between client and family members

 The Psychiatric Social Worker- visited the home of the family members on atleast one occasion to determine what the living conditions were, to ensure that the environment was conducive for the return of J.D as well as to investigate factors that may precipitate a relapse. The family members reaffirmed their commitment to make the environment conducive (based on the information that we had already received from them) for J. D. by commencing a small house in close proximity to theirs.

 The Pharmacist- had one meeting with the family members and the following pointers were discussed and written down for them: therapeutic appropriateness, over and underutilization, appropriateness of generic products, drug-disease contraindications, drug-drug interactions, incorrect drug dosage and duration of drug treatment, drug-allergy interactions, the name and description of the medication,

 the route, dosage form, route of administration and duration of therapy, special directions and precautions for preparation, administration and use by the patient/family, common severe side effects, adverse effects, interactions or therapeutic complications that may be encountered, including their avoidance and the action required if they occur, techniques for monitoring drug therapy and their relatives compliance, proper storage, prescription refill information and actions to be taken in the event of a missed dose.

 The Occupational Therapist- Though we didnt possess a trained occupational therapist, a veteran psychiatric nurse with knowledge of occupational therapy, functioned in this role. She explored various job options with the client and his family members, noting that employment, in addition to being a means of earning, was also useful in channeling his mind, hands and energy into something meaningful and would lessen the signs and symptoms from his illness.

 Expert Nurse/Psychiatric Nurse- We the

members of this group served as the coordinators, liaison and collaborators between the family members and the multimodal team. We sought to earn mutual respect for all concerned through clear communication, expert clinical practice, and a willingness to meet the demands of providing the family with psychoeducational care.

 We asked questions to ensure that

everything that was said to the family was clearly understood, where there were misunderstandings, we clarified and reinforced what was said. In further collaboration we explained the strengths and limitations of this type of therapy.

 In addition to reinforcing what was said by

the multimodal team, we also tried to provide counseling and identification of areas for additional treatment needs such as their community health centers, 4-clubs, community mental health and churches

 After weeks of family psychotherapy with

the multimodal team J.Ds family was ready to have him home, he was formally discharged.

EVALUATION
The implementation programme was successful, J.Ds family members felt sufficiently educated and empowered, and as such, they requested to have him home.

 This study has shown that with

psychoeducation, family members would be more receptive and equipped to nurse their relatives at home; however, it should be noted that this family had all the basic resources to care for their relative at home, thus it was easy to implement the programme.

 In terms of limitations there are some family

members who simply do not want their relatives home, while there are others who do not possess the resources to care for their relatives at home, thus for these there are no clear outcomes for using family psychoeducation.

 This situation clearly calls for additional

work to be done in the future. Another limitation to this study was the lack of a proper mechanism and time to track J.Ds progress, we patiently wait to see what the next five months will yield for J.D and his family, a relapse or continued progress.

 If this study is to be implemented within the hospitals general population some mechanisms need to be put in place: 1. tracking clients and family members progress, 2. dealing with family members who have little or no resources and those who do not want to their relative at home. If these are addressed, we could determine fully the success of psychoeducation in terms of reduction of admission/readmission rates.