Relapse Prevention among Caregivers of Patients with
Schizophrenia
Mrs. Josephine Gracia Britto1, Dr. Ramachandra1
1Associate
Professor, NIMHANS, Bangaluru
Corresponding Author Email: resilientjoe@gmail.com
ABSTRACT:
The biggest untapped resource in health care is the
patient and their family. Schizophrenia is a severe mental disorder which
accounts for much suffering of those affected and their families, in addition
to a cost to society estimated as 1.1% of the total burden of disease (in terms
of DALYs – disability adjusted life-years) and 2.8% of the total YLDs (years
lived with disability).(1)The ultimate goal of the treatment of people with
schizophrenia is the productive reintegration into mainstream society. The care
of persons with schizophrenia can be provided at community level through
education and psychosocial interventions to help patients and families cope
with the illness and its complications, and also to prevent relapses. The aim
is to assess the effectiveness of structured teaching programme
on knowledge regarding schizophrenia relapse prevention among care givers in
National Institute of Mental Health and Neurosciences.
The researcher adopted Pre experimental, one group
pre-test, post-test design. Based on the sampling criteria the researcher
selected 46 care givers and 30 of them were selected on the lottery method for
the analysis of the study scores. The educational programme
was conducted in groups in six sessions. The tools, Socio demographic profile
of both caregivers and patients and Knowledge Assessment Checklist of
Schizophrenia Relapse Prevention were used to collect data. Analysis is done by
Paired t-Test by Comparison of pre and post test values for the effectiveness
of the structured programme and to check the
association with socio demographic variables Pearson correlation and
independent t-Test were employed.
Paired t-Test revealed that there was a statistically
significant increase in the knowledge regarding Schizophrenia relapse
prevention among care givers. The Pearson correlation and independent
t-Test revealed that there is no association with the socio demographic
variables of the caregivers ,but there was a positive correlation with between
knowledge gain and the number of relapses i.e.,
more the number of relapses
higher is the knowledge, however this is
not statistically significant.
This study reveals that a short educational programme would be beneficial for the care givers who play
an important role in the life of the patients with schizophrenia and could
capably reduce the number of relapses. This study has implications in the
nursing service, research, administration and education.
KEY WORDS:
INTRODUCTION:
Schizophrenia is characterized by a broad
range of unusual behaviors that cause profound disruption in the lives of
people suffering from the condition, as well as in the lives of the people
around them. Schizophrenia strikes without regard to gender, race, social class
or culture. (1, 2)
As with many mental disorders, the causes of
schizophrenia are poorly understood. Friends and family commonly are shocked,
afraid or angry when they learn of the diagnosis. People often imagine a person
with schizophrenia as being more violent or out-of-control than a person who
has another kind of serious mental illness. But these kinds of prejudices and
misperceptions can be readily corrected.
Expectations become more realistic as
schizophrenia is better understood as a disorder that requires ongoing often
lifetime treatment. Demystification of the illness, along with recent insights
from neuroscience and neuropsychology, gives new hope for finding more
effective treatments for an illness that previously carried a grave prognosis.
The incidence of schizophrenia is largely
similar in developed and developing countries; there are however, indications
pointing to the fact that the outcome of this disorder is strongly influenced
by social factors, of which the family appears to be a key element. (1)
Prevalence rate for schizophrenia was 2.3
per 1000 population. The urban morbidity rate was 2 per 1000 higher than the
rural rate 3 .The meta-analysis by Reddy and Chandrashekar
estimated the prevalence of schizophrenia to be 2.7 (2.2– 3.3)/1000 population.(3)
A crude incidence rate of 4/10,000 can be adopted for estimating the burden of
schizophrenia in India. (4)
The ultimate goal of the treatment of people
with schizophrenia is the productive reintegration into mainstream society.
There is enough evidence that care of persons with schizophrenia can be
provided at community level through: Medications to relieve symptoms and
prevent relapse; Education and psychosocial interventions to help patients and
families cope with the illness and its complications, and also to prevent
relapses; and Rehabilitation that helps patients reintegrates the community and
regain educational or occupational functioning.
The goals of psychosocial rehabilitation for
people with schizophrenia encompass a variety of measures that go from
improving social competence and social support networking, to family support.
Central to this is consumer empowerment and
the reduction of stigma and discrimination, through improvement of both public
opinion and pertinent legislation. The respect for human rights is a presiding
principle to this strategy.
One of the objectives of National Mental
Health Program is ‘community participation’. Participation of the community
starts from the involvement of families. Involvement and sense of
responsibility could be improved by creating awareness about the significant
role played by the family members in the management of the mental illness and
especially in case of a chronic and severely disabling disease Schizophrenia.
Research on illness management for persons
with severe mental illness, including 40 randomized controlled studies,
indicates that psycho education improves people's knowledge of mental illness;
that behavioral tailoring helps people take medication as prescribed; that
relapse prevention programs reduce symptom relapses and rehospitalization;
and that coping skills training using cognitive-behavioral techniques reduces
the severity and distress of persistent symptoms. The authors discuss the
implementation and dissemination of illness management programs from the
perspectives of mental health administrators, program directors, people with a
psychiatric illness, and family members. (2)
Pekkala. E and Merinder. L
did the systematic review to investigate the efficacy of psycho education for
schizophrenia. The electronic searches of random controlled studies of CINAHL,
The Cochrane Library CENTRAL, The Cochrane Schizophrenia Group's Register , EMbase , MEDLINE , PsycLit , and Sociofile were
undertaken. Evidence from trials suggests that psycho educational approaches
are useful as a part of the treatment program for people with schizophrenia and
related illness and if the interventions are brief and inexpensive should make
them attractive to managers and policy makers. (5)
McFarlane WR. et al in their article project the fact that family
psycho education has emerged as a treatment of choice for schizophrenia,
bipolar disorder, major depression, and other disorders. More than 30
randomized clinical trials have demonstrated reduced relapse rates, improved
recovery of patients, and improved family well-being among participants.(6)
Jose.
G.M and Alexjandra. C
studied that a family psycho
educational program could change the negative attitude in relatives of patients
with schizophrenia.(7)
Tanveer. N and Rukhsana.
K examined efficacy of psycho
educational interventions, in relapse prevention in patients with
Schizophrenia Relapse rate in psycho
education was lower (5.8%) compared with control group (35.7%) at six month
follow up. Their symptoms were significantly less severe on PANSS. (8)
Xia.J, Merinder. L.B and
Madhvi. R.B
assessed the effects of psycho educational interventions compared with
standard levels of knowledge provision by a systematic review and concluded
that Psycho education does seem to reduce relapse, readmission and encourage
medication compliance, as well as reduce the length of hospital stay in these
hospital-based studies of limited quality and also some sort of psycho education could be
clinically effective and potentially cost beneficial.(9)
From the results of the various studies it is
obvious that a family psycho education programme
would be definitely beneficial the caregivers to effectively manage the
patients at home and also hospital. Less Indian studies were found regarding
the beneficial effects of family psycho education especially the short course programmes. Hence the researcher opted to choose this
study.
MATERIALS AND METHODS:
The tool consists of two data sheets.
Ø Socio demographic profile of both caregivers
and patients.
Ø Knowledge Assessment Checklist of
Schizophrenia Relapse Prevention
1. Socio demographic profile of caregivers include relationship with the
patient, sex, age, location, educational status , marital status, type of
family, occupation, duration of care given
2. Socio demographic profile of patients
include sex, age, location, education, marital status, type of family,
occupation, duration of illness and number of relapses.
3. Knowledge Assessment Checklist of
Schizophrenia Relapse Prevention
It comprises five domains:
1. Information about the illness
2. Knowledge about symptomatology
3. Communicating with the client
4. Knowledge of Schizophrenia relapses
5. Knowledge of relapse prevention
TABLE: 1 – CAREGIVERS’ SOCIO DEMOGRAPHIC PROFILE
|
Profile Details |
Frequency |
Percentage |
|
|
RELATION |
Father |
17 |
56.70% |
|
Mother |
6 |
20.00% |
|
|
Spouse |
2 |
6.70% |
|
|
Sibling |
5 |
16.70% |
|
|
SEX |
Male |
22 |
73.30% |
|
Female |
8 |
26.70% |
|
|
AGE IN YEARS |
20-30 |
3 |
10.00% |
|
30-40 |
2 |
6.70% |
|
|
40-50 |
9 |
30.00% |
|
|
50-60 |
11 |
36.70% |
|
|
60-70 |
5 |
16.70% |
|
|
HABITAT |
Rural |
12 |
40.00% |
|
Urban |
18 |
60.00% |
|
|
EDUCA-TION |
Primary |
4 |
13.30% |
|
Secondary |
9 |
30.00% |
|
|
Graduate |
11 |
36.70% |
|
|
Post Graduate |
6 |
20.00% |
|
|
MARITAL STATUS |
Married |
27 |
90.00% |
|
Unmarried |
3 |
10.00% |
|
|
FAMILY TYPE |
Nuclear |
23 |
76.70% |
|
Joint |
7 |
23.30% |
|
|
OCCUPA-TION |
Unemployed |
0 |
13.30% |
|
Homemaker |
4 |
||
|
Employed in organization |
18 |
60.00% |
|
|
Self-employed |
5 |
16.70% |
|
|
Retired |
3 |
10.00% |
|
|
DURA-TION OF CARE in years |
2 |
9 |
30.00% |
|
3 |
8 |
26.70% |
|
|
4 |
5 |
16.70% |
|
|
5 |
1 |
3.30% |
|
|
6 |
2 |
6.70% |
|
|
7 |
1 |
3.30% |
|
|
9 |
1 |
3.30% |
|
|
10 |
1 |
3.30% |
|
|
11 |
2 |
6.70% |
|
List of all patients with Schizophrenia was
collected from all the wards. The researcher contacted their family members.
The subjects were selected according to the sampling criteria. Totally 46
caregivers participated in the study in 6 groups. Structured Teaching Programme was conducted in 6 sessions, 1hour each. First forty minutes was for psycho education
and last twenty minutes was dedicated to clearance of doubts and sharing of
experiences. Post test was conducted in the last session. To analyze socio
demographic data; descriptive statistics like Percentage, Frequency distribution,
Central tendency and Standard deviation were used.
To compare the pretest and post test; paired
t-Test, Central tendency and Standard deviation were used.
To find the association of socio demographic
data of caregivers knowledge level Independent sample t-Test, Central tendency
and Pearson Correlation were employed.
RESULTS:
Table -1 depicts the caregivers’ socio
demographic profile The profile
collected were Relationship with the client, sex, age, habitat, education,
marital status , family type, occupation and
duration of care which corresponds to the duration of illness of the client.
TABLE: 2 PATIENTS’ SOCIO DEMOGRAPHIC PROFILE
|
Profile details |
Frequency |
Percentage |
|
|
SEX |
Male |
15 |
50.00% |
|
Female |
15 |
50.00% |
|
|
AGE IN YEARS |
15-25 |
8 |
26.70% |
|
25-35 |
11 |
36.70% |
|
|
35-45 |
8 |
26.70% |
|
|
45-50 |
3 |
10.00% |
|
|
HABITAT |
Rural |
9 |
40% |
|
Urban |
19 |
60% |
|
|
EDUCATION |
Primary |
2 |
6.70% |
|
Secondary |
11 |
36.70% |
|
|
Graduate |
14 |
46.70% |
|
|
Postgraduate |
3 |
10.00% |
|
|
MARITAL STATUS |
Married |
3 |
10.00% |
|
Unmarried |
25 |
83.30% |
|
|
Widowed |
1 |
3.30% |
|
|
Separated |
1 |
3.30% |
|
|
FAMILY TYPE |
Nuclear |
18 |
60.00% |
|
Joint |
12 |
40.00% |
|
|
OCCUPATION |
Unemployed |
7 |
23.30% |
|
Student |
13 |
43.30% |
|
|
Homemaker |
3 |
10.00% |
|
|
Employed in organization |
5 |
16.70% |
|
|
Self-employed |
2 |
6.70% |
|
|
DURATION OF ILLNESS in years |
2 |
9 |
30.00% |
|
3 |
7 |
23.30% |
|
|
4 |
5 |
16.70% |
|
|
5 |
1 |
3.30% |
|
|
6 |
3 |
10.00% |
|
|
7 |
1 |
3.30% |
|
|
9 |
1 |
3.30% |
|
|
10 |
1 |
3.30% |
|
|
11 |
2 |
6.70% |
|
|
NUMBER OF RELAPSE |
1 |
6 |
20.00% |
|
2 |
7 |
23.30% |
|
|
3 |
5 |
16.70% |
|
|
4 |
6 |
20.00% |
|
|
5 |
2 |
6.70% |
|
|
8 |
1 |
3.30% |
|
|
10 |
2 |
6.70% |
|
|
12 |
1 |
3.30% |
|
Table -2 consists of the patients’ profile
which includes sex.age, habitat, education, marital
status, family type, occupation, duration of illness, number of relapses.
TABLE-3 - PAIRED t-TEST FOR COMPARISON OF
PRE AND POST TEST VALUES
|
Number of Care Givers N = 30 |
||||||
|
PAIRS |
Mean |
Standard Deviation |
Standard Error Mean |
t-value |
Significance(P) P=0.05 |
|
|
Domain 1 |
Pre test |
9.2 |
2.024 |
0.37 |
12.187 |
0 |
|
Post test |
13.5 |
1.548 |
0.283 |
|||
|
Domain2 |
Pre test |
7.4 |
1.429 |
0.261 |
6.869 |
0 |
|
Post test |
9 |
0.83 |
0.152 |
|||
|
Domain 3 |
Pre test |
7.97 |
2.456 |
0.448 |
6.246 |
0 |
|
Post test |
10.9 |
1.373 |
0.251 |
|||
|
Domain 4 |
Pre test |
7.27 |
1.76 |
0.321 |
11 |
0 |
|
Post test |
10.93 |
1.258 |
0.23 |
|||
|
Domain 5 |
Pre test |
11.03 |
1.474 |
0.269 |
10.422 |
0 |
|
Post test |
13.83 |
1.177 |
0.215 |
|||
|
Total (all domains) |
Pre test |
42.87 |
6.74 |
1.231 |
12.743 |
0 |
|
Post test |
58.17 |
3.505 |
0.64 |
|||
FIGURE:
1 The comparative picture of minimum, maximum marks and the mean of pre test and the post test of all the domains
All the socio demographic variables of
caregivers and only number of relapses was considered in patients’ profile
based on the assumption that it would affect the knowledge level of the
caregivers. Independent t-Test was
carried out to find the association between socio demographic variables of
caregivers and knowledge gain.
The Pearson coefficient was 0.117 which
shows that there is a positive correlation between the duration of care given
and knowledge regarding relapse prevention but it was not significant as P
= 0.536. (p>0.05)
The Pearson correlation coefficient between
number of relapses and knowledge gain was 0.189.This shows that there is a
positive correlation but the P value was not significant as P=
0.318(p>0.05).
The study did not find any significant
association with the demographic variables and knowledge gain regarding
schizophrenia relapse prevention.
The table 3 shows the Paired T-Test
comparing the pre and post test values of the study. The first domain’s mean value of pretest was 9.2 and
post test was 13.5; the t-value is 12.187 which was significant(p<0.05) .The
second domain’s pretest mean was 7.4 where as post test mean was 9;the t-value
was 6.869 which was statistically significant(p<0.05).
The third domain’s pre test mean was
7.97,post test mean was 10.9,t-value was 6.246 and the rise in values were
significant as p <0.05.The pre test of fourth domain was 7.24, its post test
value was 10.93 and the t-value calculated was 11.The increase in this domain
was also statistically significant as
p<0.05.The last domain’s pre test mean was 11.03 and post test mean was
13.83.Its t-value was 10.422 and p value was less than 0.05 which shows that
the result is statistically significant.
The entire test’s mean of pre test is 42.7
and post test is 58.17 an increase of nearly fifteen points shows that the
educational programme was effective. The t- value
computed was 12.743 with high statistical significance as p<0.05.
This bar diagram (fig. 1) represents the
collective pre and post test scores of all domains. The minimum pre test was 31
and post test was 56. The maximum pretest mark was 51 and post test maximum was
64.The pre test mean score was 42.7 and post test mean was 58.17.
The overall observation of the study was
there is a marked rise in the post intervention score which reflects the
effectiveness of the structured teaching program of schizophrenia relapse
prevention.
DISCUSSION:
The studies by Goldstein. M.J et al(10),
Herz MI.et al(11) and Pharoah F, Mari J, Rathbone J, Wong W (12) support the findings of
the present study.
The systematic review done by Goldstein. M.J.
et al confirmed the positive effects of a family-based psycho educational
program on delaying the recurrence of a schizophrenic episode. Of the 23
studies that met original inclusion criteria, six (26%) demonstrated
significant effects for treatment adherence. Seven (44%) of the additional 16
studies also demonstrated significant effects. A majority of the studies that
reported significant effects found improved clinical outcomes in the
intervention group at follow-up (69%; N=9). This clinical advantage was
manifest in fewer psychiatric symptoms, fewer hospitalizations, and fewer days
in the hospital and prolonged or extended community tenure. (10)
Herz MI, Lamberti JS, Mintz J, Scott R a program for relapse prevention (PRP)
is more effective than treatment as usual (TAU) in reducing relapse and rehospitalization rates(11). Similarly, Pharoah F, Mari J, Rathbone J,
Wong W after their systematic review to estimate the effects of family
psychosocial interventions conclude that; Family interventions reduce the
number of relapse events and hospitalizations (12)
The studies by Kavitha.
R.R and Tanveer. N and Rukhsana.
K also found no relation between the sociodemographic
variables and knowledge gain about schizophrenia relapse prevention.(13,9)
CONCLUSION:
Psycho education was originally conceived as
a composite of numerous therapeutic elements within a complex family therapy
intervention. Patients and their relatives were, by means of preliminary
briefing concerning the illness, supposed to develop a fundamental understanding
of the therapy and further be convinced to commit to more long-term
involvement. Psycho education focus on the didactically skillful communication
of key information. Through this, patients and their relatives should be
empowered to understand and accept the illness and cope with it in a successful
manner. At the same time, there is a need for culturally sensitive family
treatments offered by nurses especially with regard to psycho education. It is
supposed that this increased knowledge and insight will enable people with
schizophrenia to cope in a more effective way with their illness, thereby
improving prognosis. Most of the time , the patient and the family find nurses more approachable and nurses are
the first hand health care providers; technically this necessitate the nurses
to test the psycho education empirically.
REFERENCES:
1.
World
Health Organization . Atlas: Country profiles on mental health resources.
Geneva, WHO(2001
2.
Kim.TM.
et al, Illness Management and Recovery:
A Review of the Research, Schizophrenia Bulletin-2005.25(2)2-10.
3.
Reddy
MV, Chandrashekar CR. Prevalence of mental and
behavioral disorders in India: A meta-analysis. Indian Journal of Psychiatry
1998;40:149–57
4.
Ganguli HC. Epidemiological finding on prevalence of mental disorders in India.
Indian Journal of Psychiatry 2000;42:14–20.
5.
Pekkala E., Merinder L. Psychoeducation
for schizophrenia. Cochrane Database Syst Rev,
(2002) Issue 2, Art No.CD002831
6.
Merinder á A.G. and H.D. Laugesen, Patient
and relative education in community psychiatry:a
randomized controlled trial regarding its effectiveness Social Psychiatry Psychiatry
Epidemiology (1999) 34: 287±294
7.
Herz.
MI, Lamberti .JS, Mintz. J, Scott .R, et al. Program for relapse prevention in
schizophrenia: a controlled study. Archives of General Psychiatry. Chicago: Mar
2000.57( 3) 277
8.
Sota S, etal, Effect of a family psychoeducational program on relatives of schizophrenia
patients. Psychiatry Clinical Neurosciences. 2008 Aug;62(4):379-85.
9.
Pharoah F, Mari J, Rathbone J, Wong W. Family intervention
for schizophrenia (Review)The Cochrane Library .2010, Issue 12.Art. No.:
CD000088
10.
Goldstein
MJ. Psychoeducation and relapse prevention, International
Journal of Clinical Psychopharmacology (1995) Jan9 (5) 59-69
11.
Stenberg,
J.H., et al (1998) The effect of symptom self-management training on rehospitalization for chronisc
schizophrenia in Finland. International Review of Psychiatry, 58-61.
12.
Tanveer. N and Rukhsana. K, Effects of family psycho
education on relapse prevention of Schizophrenia patients in Pakistan, Psychiatric
residents July-December 2009, 6 (2)73
13.
Kavitha. R.R(1999) Effectiveness of Nursing intervention on the family members’
knowledge about drug compliance of clients with Schizophrenia, Unpublished
Thesis for Masters in Psychiatric Nursing, NIMHANS.
Received on 29.07.2013 Modified on 08.10.2013
Accepted on 04.11.2013 © A&V Publication all right reserved
Asian J. Nur. Edu. & Research 4(1): Jan.-March 2014; Page 140-144