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RESEARCH ARTICLE |
https://doi.org/10.5005/jp-journals-10067-0176 |
Effect of Psychoeducation on Expressed Emotion among Caregivers of Patients with Mental Disorders
1,3Department of Psychiatric Nursing, Government College of Nursing, Kozhikode, Kerala, India
2Government College of Nursing, Kozhikode, Kerala, India
4Department of Psychiatry, Government Medical College, Kozhikode, Kerala, India
Corresponding Author: Saleem TK, Department of Psychiatric Nursing, Government College of Nursing, Kozhikode, Kerala, India, Phone: +91 9497604817, e-mail: tksaleem@gmail.com
How to cite this article: Kochumon R, Sanil M, Saleem TK, et al. Effect of Psychoeducation on Expressed Emotion among Caregivers of Patients with Mental Disorders. Ind J Priv Psychiatry 2024;18(2):57–60.
Source of support: Nil
Conflict of interest: None
Received on: 14 March 2024; Accepted on: 20 April 2024; Published on: 26 July 2024
ABSTRACT
Background: Expressed emotion (EE) is a strong predictor of outcomes in patients with mental disorders. Effective psychoeducation can improve communication between patients and caregivers. Low levels of EE are associated with better patient outcomes.
Objectives: The present study was aimed to assess the effect of psychoeducation on EE among caregivers of patients with mental disorders who were admitted to a tertiary care teaching hospital in Kerala.
Methods: A pre-experimental, pre-test, post-test design was used. The sample size was 30, who were family members of patients with serious mental disorders. Expressed emotion family questionnaire (FQ) and sociopersonal data sheet were used. Ethical permission was obtained. Data were subjected descriptive and inferential analysis.
Results: The findings show that there was a significant difference (p < 0.01) in the mean score of FQ before and after psychoeducation, as well as the on subdomains scores of critical comments (CCs) (p = 0.001) and emotional overinvolvement (p = 0.001).
Conclusion: Expressed emotion in caregivers of patients with mental illness can be improved with effective and scientifically communicated psychoeducation.
Keywords: Caregivers, Common mental disorders, Expressed emotion, Psychoeducation.
INTRODUCTION
Mental illnesses continue to rank among the top 10 global causes of burden.1 Treatment gaps and treatment dropouts continue to be major obstacles despite advancements in the diagnosis and treatment of mental illnesses.2 Patients with serious mental illnesses who exhibit non-adherence or partial adherence had higher rates of relapse, rehospitalization, and attempted suicide.3 Expressed emotion (EE) contributes significantly to the occurrence of relapse in individuals with severe mental illness.4 EE describes how important family members treat a person who has a mental illness, which is typified by high criticism, hostility, or emotional over involvement.5 Expressed emotion has unfavorable effects in neurological and mental illnesses.6 Research accumulated throughout time indicates that EE is harmful to individuals with a range of mental illnesses.6–8 In the Indian scenario, mostly, family members take care of the patients on a daily basis, supervise their medication, transport them to the hospital, and take care of their financial needs.9 The considerably improved prognosis for schizophrenia in Asian countries may be attributed to family assistance for mentally ill patients.10 Because family members actively participate in the patient’s treatment, the illness has a significant impact on them, which ultimately results in a high level of EE toward the patient.11,12 There are limited studies on the impact of EE on illness outcomes in India.12
Several Indian studies have documented a lack of awareness and comparatively low mental health literacy among family caregivers, mental health patients, and treatment providers.13,14 Psychoeducational interventions have been shown to be successful in lowering EE levels and enhancing family functioning for those who care for people with serious mental illnesses. When caregivers receive psychoeducation in addition to the standard patient care, their perceptions of load are reduced, and the patients’ clinical course improves.15,16 Family interventions with psychoeducation have been proven to be successful in treating schizophrenia.17 In schizophrenia, psychoeducational interventions lower the risk of relapse and rehospitalization.18
The goal of psychoeducation is to educate patients and their families on the many aspects of mental disease and how to treat it, enabling them to collaborate with mental health providers for improved results.19 It combines the factor of empowerment of the affected with scientifically founded treatment expertise in as efficient a manner as possible.20 Psychoeducation often consists of a few fundamental facts about a specific mental illness that patients and their families are to be informed about.19 Brochures, books, and films are used in psychoeducation together with dialogical support and supervision to help retain the information that is communicated orally.20
This study was aimed to evaluate the effect of psychoeducation on EE among caregivers of patient with mental disorders.
METHODS
A pre-experimental one-group, pre-test and post-test design was used for the study. The study sample consisted caregivers of patients with mental disorders selected by consecutive sampling. Sample size was empirically set at 30. Patients with mental disorder in this study refers to patients who are diagnosed to have schizophrenia, bipolar affective disorder, schizoaffective disorder, and alcohol dependence as per ICD 10 criteria by the treating psychiatrist.21 The tools included the General Health Questionnaire-5 (GHQ-5)22 to screen the participants for mental health problems, a data sheet to assess the selected sociopersonal variables among patients and caregivers, and a 20-item, standardized, family questionnaire (FQ) to assess the expressed emotion among caregivers of patients with mental disorders.23 The FQ has a score range of 0–80, and the total score was categorized in to high (50–80) and low (1–49). The scale has two subscales, critical comments (CCs) and emotional overinvolvement (EOI). Family members of patients with mental disorders, who were screened with GHQ-5 for mental health problems, and who were able to read and write Malayalam language were included in the study. The scales were translated into Malayalam, and language validity was established using back-to-back translation. Translated FQ was subjected to internal consistency reliability and found to have a Cronbach’s alpha of 0.76. Caregivers who were not staying with patients regularly and those who had serious physical illness were excluded. A pilot study was conducted and study was found to be feasible. The data collection period of the study was 6 weeks. The group attended half-an-hour psychoeducation for 3 days in the afternoon after pre-test. The post-test conducted after third session of psychoeducation. The data were analyzed using descriptive and inferential statistics.
Psychoeducation in this study refers to process of communicating knowledge on common mental disorders, managements, issues related to caring mentally ill, EE, interventions for EE. The module included sessions of 30 minutes duration in the form of lecture cum discussion and also by providing a self-explanatory leaflet for a group of caregivers of patients with mental disorders. Content was prepared on the basis of deficit model of psychoeducation, which suggests that an inadequate knowledge of information about illness results in negative behavior and disseminating of that knowledge would reduce this behavior. Certain aspects of interaction model was also incorporated in this module where family members make their own explanations of the patients’ illness and which is clarified by the professionals.6,24
General Health Questionnaire-5 was administered to the participants before the first session to screen for any mental health problems and four participants were excluded. In the first session, participants were introduced about the common mental disorders. Second session was about the issues of caring individuals with mental illness and specific aspect of care of these patients. In the third session, participants were introduced about the concept of EE and how it adversely affects the patient outcome.
The study was approved by the Institutional Ethical Committee and administrative permission was obtained from the institutional authority. After explaining the purpose of the study, written consent was obtained from the participants. The first investigator collected the data and imparted the psychoeducation. The study was conducted during the month of January and February, 2019.
RESULTS
Sample Characteristics
In the present study, 33.3% of the participants belonged to the age group of 40–49 years, 53.3% were females and 56.7% were Hindu by religion. Among the participants 43.3% of the participants were having primary level education and 83.3% were married. Most of the participants were residing at rural area (80.0%), 76.7% of the participants belonged to nuclear family and 36.6% of the participants were private employees. The results showed that 70.0% of participants belonged to BPL category, 36.7% of participants were parents of the patients and 73.3% of participants were spending 5–7 days in a week with the patient (Table 1).
| N = 30 | ||
|---|---|---|
| Variable | Category | f (%) |
| Age | 20–29 | 5 (16.6) |
| 30–39 | 9 (30) | |
| 40–49 | 10 (33.3) | |
| 50–59 | 2 (6.7) | |
| >60 | 4 (13.4) | |
| Sex | Male | 14 (46.7) |
| Female | 16 (953.3) | |
| Religion | Hindu | 17 (56.7) |
| Christian | 4 (13.3) | |
| Islam | 9 (30.0) | |
| Education | Primary education | 13 (43.3) |
| Secondary | 5 (16.7) | |
| Higher secondary | 8 (26.7) | |
| Degree | 4 (13.3) | |
| Marital status | Married | 25 (83.3) |
| Single | 2 (6.7) | |
| Widow | 3 (10) | |
| Area of residence | Rural | 24 (80.0) |
| Urban | 6 (20.0) | |
| Type of family | Nuclear family | 23 (76.7) |
| Joint family | 7 (923.3) | |
| Occupation | Government job | 7 (23.3) |
| Private employee | 11(36.6) | |
| Self-employee | 5 (16.7) | |
| Home maker | 4 (13.4) | |
| Manual labor | 3 (10) | |
| SES | BPL | 21 (70) |
| APL | 9 (30) | |
| Relationship to the patient | Parents | 11 (36.7) |
| Siblings | 8 (26.7) | |
| Spouse | 9 (30) | |
| Children | 1 (3.3) | |
| Others | 1 (3.3) | |
In the present study, patient characteristics shows, 26.6% belonged to the age group of 30–39 years, 56.7% were females, and 36.7% studied up to primary level. One-third (33.3%) of patients were unemployed, 63.4% were married, 70.0% had age-at-onset of illness <25 years of age. Patient characteristics also show, 56.7% had >15 years of illness, 46.7% had 5–10 times of previous hospitalizations and 40.0% were diagnosed as schizophrenia (Table 2).
| N = 30 | ||
|---|---|---|
| Variable | Category | f (%) |
| Age | <20 | 7 (23.3) |
| 20–29 | 7 (23.3) | |
| 30–39 | 8 (26.6) | |
| 40–49 | 3 (10) | |
| 50–59 | 5 (16.7) | |
| Sex | Male | 13 (43.30 |
| Female | 17 (56.7) | |
| Education | Primary education | 13 (43.4) |
| Secondary | 10 (33.3) | |
| Higher secondary | 4 (13.3) | |
| Degree | 3 (10.0) | |
| Occupation | Government job | 4 (13.3) |
| Private employee | 5 (16.7) | |
| Self-employee | 3 (10.0) | |
| Unemployed | 10 (33.3) | |
| Manual labor | 6 (20.0) | |
| Home maker | 2 (6.7) | |
| Marital status | Married | 19 (63.4) |
| Single | 4 (13.3) | |
| Widow | 3 (10.0) | |
| Divorced/Separated | 4 (13.3) | |
| Number of previous hospital admission | <5 times | 7 (23.3) |
| 5–10 times | 14 (46.7) | |
| 11–15 times | 9 (30.0) | |
| Diagnosis | Schizophrenia | 12 (40) |
| Schizoaffective disorder | 4 (13.3) | |
| Bipolar disorder | 7 (23.3) | |
| Alcohol dependence syndrome | 7 (23.3) | |
Expressed Emotion among Caregivers
The present study revealed that the mean pre-test FQ score was 54.73 (SD = 9.69) which can be regarded as high EE and the post-test FQ score was 45.40 (SD = 7.06). Psychoeducation was imparted in three sessions and the post-test scores were evaluated after the third session. The pre-test and post-test FQ sores were subjected to paired t-test, and the findings showed that there was significant difference (p < 0.01) in the mean score of FQ before and after psychoeducation. Similarly, subscales of CC score and EOI was also significantly different between before and after the intervention. (p = 0.001) (Table 3). When FQ score was categorized into low EE and high EE group, it was seen that 76% caregivers had high level of expressed emotion prior to the intervention. Post-test score analysis of EE shows that the proportion high EE was 23.3% (Table 4).
| (N = 30) | ||||
|---|---|---|---|---|
| Sub scale | Pre-test mean (SD) | Post-test mean (SD) | t-value | p-value |
| Critical comments (CCs) | 26.87 (5.58) | 22.13 (4.19) | 9.73 | 0.001** |
| Emotional overinvolvement (EOI) | 27.87 (4.89) | 23.36 (3.35) | 8.64 | 0.001** |
| EEFQ (Total score) | 54.73 (9.69) | 45.40 (7.06) | 10.79 | 0.001** |
| N = 30 | ||||
|---|---|---|---|---|
| Variablesexpressed emotion (category) | Pre-test | Post-test | ||
| Frequency | Percentage | Frequency | Percentage | |
| High (50–80) | 23 | 76% | 8 | 27% |
| Low (1–49) | 7 | 23.3% | 22 | 73% |
DISCUSSION
Numerous studies have found that EE is a major factor in recurrence among mental illness.3–8 In this study, a group of 30 caregivers of patients with mental illness from a tertiary care psychiatric unit were subjected to a structured psychoeducation program in three sessions and evaluated for its effect on the EE using a self-report scale. We found a significant difference in EE score before and after the psychoeducation. A fundamental component of psychotherapy for individuals with schizophrenia and their families is psychoeducation.20 Poor clinical outcomes for patients with mental disorders are predicted by EE.4 Relapses worsen the result by causing distress to the patient and their family. Previous research has examined the significance of family-based psychoeducational interventions in preventing relapse and rehospitalization in individuals with severe mental disorders.18 Close relatives’ awareness of disease and tendency to hold the patient responsible for the disorder have an emotional impact on the relationships between patients and their relatives.25 In Indian culture, families are frequently the first to provide care for those with mental health issues. Involving family members in the care of mentally ill people may improve their prognosis.26 There are several obstacles associated with family engagement in the treatment of, such as the caregiving load and cultural norms of interaction.27
One element of EE that is linked to recurrence in severe mental illness is CCs, which psychoeducation should focus on.28 We found a significant difference in CC score before and after psychoeducation. The categories Shimodera uses to categorize the CCs reported in the Camberwell Family Interview (CFI) include positive and negative symptoms, adhering to medical advice, problems in life, acting inappropriately in social situations, hostility, rejection, and premorbid personality.28 They concluded that as positive symptoms were the most frequently commented on topic, it should be a main topic in family psychoeducation.
Emotional overinvolvement is a measure of a relative of a mental patient’s overbearing, overly self-sacrificing, or overly emotional behavior.29 Our study found a significant difference between the mean scores of EOI subscale scores before and after the psychoeducation. Previous reports have shown the detrimental impact of parental emotional overinvolvement on affective disturbances in patients with schizophrenia.30 So, psychoeducation should specifically focus on the excessive emotional involvement of family members which affects the independence of the patient.
We conclude that psychoeducation is an effective therapeutic tool in reducing CC and EOI in caregivers of patients with mental disorders. Despite the design limitations and small sample size, this study has implications in clinical practice.
ORCID
Saleem TK https://orcid.org/0000-0002-9302-2895
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