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.
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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