This Web site is a component of the SAMHSA Health Information Network
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This Web site is a component of the SAMHSA Health Information Network |
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This Web site is a component of the SAMHSA Health Information Network. |
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Evidence-Based Practices: Shaping Mental Health Services Toward RecoveryImplementation Resource Kit User's GuideSpecial Populations AppendixA review of the literature addressing the range of populations for which family psychoeducation has demonstrated efficacy or effectiveness, including factors such as age, race, ethnicity, gender, diagnosis, nationality, institutional setting, sexual orientation, and rural or urban location. The most consistent finding from the family psychoeducation (FPE) literature has been the absence of specific client factors predicting better outcomes. Diagnosis may be the closest to a specific indicator, but that is primarily because there are fewer published studies of outcomes for diagnoses other than schizophrenia. Specifically, symptomatologies, age, gender, disability status, prior hospitalization, duration of illness and education have been examined and none have proven to be strong or consistent predictors. Family expressed emotion at baseline has proven to predict outcome within studies of treatment effects, as it has in studies without intervention (1, 2). However, Falloon showed that outcome was better predicted by coping skill improvements in treatment for family members (3). At present, FPE has been shown to be most effective for individuals diagnosed with schizophrenia. There have been at least 20 controlled trials, involving nearly 5000 consumers and their families, and two are underway in Scandinavia that will involve nearly 1000 consumers and their families. Outcome has been remarkably consistent across all but two of the published clinical trials (4, 5). For that reason, schizophrenia is the principal diagnostic focus of this toolkit. Briefly described within the Workbook, modifications have been developed and tested for bipolar disorder (6, 7), depression (8), borderline personality disorder (9) and OCD (10). Multifamily group versions for these disorders have recently been described in Multifamily Groups in the Treatment of Severe Psychiatric Disorders (11). Single-family versions have been tested and found to be effective for bipolar disorder, and studies are underway for the other disorders. Within-study comparisons of relapse rates for different ethnic groups have led to at least one set of indications, in this case for multi- or single-family formats. One of the U.S. studies was a large, multisite effectiveness study conducted in state- or city-operated clinics and hospitals, in which multifamily groups had significantly lower (by about 1/3) relapse rates in five of the six sites (12). This study also identified a subgroup for which the single-family format was more effective—African-American families with low expressed emotion and patients with unusually good response to medication during the index hospitalization (13). First-episode cases, regardless of other characteristics or ethnicity, did substantially better in multifamily group than in single-family sessions, a counter-intuitive finding, but one that was significant (13). Randomized controlled trials of family psychoeducation have been conducted in settings and other countries in which there were significant numbers of Caucasian, African-American, Asian and Latino subjects. Earlier studies have been conducted in London (14-16), Pittsburgh (2), New York City(17), New York State (12), Los Angeles(1, 18), Philadelphia (19), Atlanta (19), New Jersey (20), and China (21, 22) and others. Recent studies in Spain (23-25), China (26-29), Scandinavia (30), Japan (submitted) and the U.K. (31) have demonstrated the same robust effects as in prior studies in English-speaking and other countries. That these effects are additive to, but not substitutive for, antipsychotic medication was illustrated in a recent German study (32). The one exception to generalized effectiveness was noted in a study by Telles and colleagues in Los Angeles, in a Spanish-speaking immigrant sample (5). There was a reversed effect for behavioral family management (using a single-family format) among those from a less acculturated subgroup and no effect for those from the more acculturated subgroup. It appeared that the Los Angeles sample’s immigrant status may have negated the effects of family intervention. At present, a study is underway testing the efficacy of psychoeducational multifamily groups in Latino people. Though early indications are much more positive than in the prior single-family study, final conclusions need to await outcome analysis. Although more replications are desirable, all the evidence to date suggests that the effectiveness of family psychoeducation compared to conventional individual therapy generalizes to nearly all major cultural populations: British-American and Australian, African-American, Spanish/Latino, Scandinavian/Northern European, Chinese and Japanese. On the other hand, anecdotally, we know that culture and language pose significant barriers to providing family psychoeducation in some populations and, in any case, require culturally sensitive adaptations and need to be further explored empirically. Some client factors have not been systematically examined in the literature. For example, we know of no studies that have examined sexual orientation and how that might affect outcomes in family psychoeducation programs. Community characteristics do not appear to impose a major barrier to implementing this approach. Family psychoeducation has been successfully implemented in both very urban and very rural settings, as well as in mid-sized cities and suburbs. Ironically, some of the most impressive outcomes have occurred among minority members of distressed and poverty-stricken urban populations (1, 12, 19). Many different states have implemented the model (33-35). Nearly all of the controlled research on effectiveness has been conducted in outpatient clinics and community mental health centers, beginning treatment in several studies during an inpatient hospital stay. The multifamily group model was developed in a partial hospital in the South Bronx of New York City. The extent to which family psychoeducation can be successfully adapted to other types of provider agencies is not known. Ranz and colleagues developed an adaptation for application in community residences, with or without family participation, that appeared to alleviate stresses within the residences and improved outcomes, but a rigorous trial of this approach has not been completed (36). References
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