Expressed emotions, burden and family functioning in schizophrenic and bipolar I patients of a multimodal intervention programme: PRISMA

Abstract

Introduction

Bipolar disorder and schizophrenia are causes of major suffering in patients. Nevertheless, they also affect family and caregiver functioning. This is important because the participation and involvement of families and caregivers is essential to achieve an optimal treatment.

Objective

To describe the level of expressed emotions, burden, and family functioning of bipolar and schizophrenic patients and, to evaluate the efficacy of the multimodal intervention (MI) versus traditional intervention (TI) in family functioning and its perception by patients and caregivers.

Material and methods

A prospective, longitudinal, therapeutic-comparative study was conducted with 302 patients (104 schizophrenic and 198 bipolar patients) who were randomly assigned to a MI or TI groups of a multimodal intervention programme PRISMA. MI group received care from psychiatry, general medicine, neuropsychology, family therapy, and occupational therapy. TI group received care from psychiatry and general medicine. Hamilton, Young and SANS, SAPS scales were applied to bipolar and schizophrenic patients, respectively. The EEAG, FEICS, FACES III and ECF were also applied at the initial and final time.

Results

There were statistically significant differences in socio-demographic and clinical variables in schizophrenia vs bipolar group: 83% vs 32.2% were male, 37 vs 43 mean age, 96% vs 59% were single, 50% vs 20% unemployed, and 20% vs 40% had college studies. In addition, 2 vs 2.5 numbers of hospitalisations, 18 vs 16 mean age of substance abuse onset and, 55 vs 80 points in EEAG. There were no statistically significant differences in family scales after conducting a multivariate analysis on thr initial and final time in both groups.

Conclusions

This study did not show changes in variables of burden and family functioning between bipolar and schizophrenic groups that were under TI vs MI.

Resumen

Introducción

El trastorno afectivo bipolar (TAB) y la esquizofrenia son causas importantes de sufrimiento para los pacientes y sus familias, pues se afectan su funcionamiento y su dinámica normal. Esto es importante, ya que la implicación de la familia es esencial para un tratamiento óptimo del paciente.

Objetivo

Describir el nivel de emociones expresadas, la carga y el funcionamiento de las familias de los pacientes bipolares y esquizofrénicos y evaluar la eficacia de la intervención multimodal (IM) en comparación con la intervención tradicional (IT) en el funcionamiento familiar y en la percepción que de este tienen el paciente y sus cuidadores.

Material y métodos

Se realizó un estudio prospectivo, longitudinal, terapéutico-comparativo, con una muestra de 302 pacientes (104 con diagnóstico de esquizofrenia y 198 con TAB) aleatorizados a un grupo de IM y otro de IT dentro de un programa de salud mental con énfasis en reducción de la carga, el daño y el gasto social de la enfermedad mental (PRISMA). Los pacientes asignados a la IM recibían atención por psiquiatría, medicina general, neuropsicología, terapia de familia y terapia ocupacional, y los pacientes asignados a IT recibían atención por psiquiatría y medicina general. Las escalas realizadas al inicio y al final de las intervenciones fueron las de Hamilton y Young, SANS y SAPS, para pacientes bipolares y esquizofrénicos respectivamente. A ambos grupos se aplicaron las escalas EEAG, FEICS, FACES III y ECF.

Resultados

Se encontraron diferencias estadísticamente significativas en las variables sociodemográficas y clínicas entre los grupos de pacientes con TAB y con esquizofrenia. Tras hacer un análisis multivariable MANCOVA, no se observaron diferencias estadísticamente significativas en los resultados entre los momentos inicial y final en los grupos de pacientes con TAB y con esquizofrenia según las escalas FEICS, FACES III y ECF.

Conclusiones

Este estudio no evidencia un cambio en la carga y el funcionamiento familiar entre los grupos sometidos a IM y a IT de pacientes bipolares y esquizofrénicos.

Introduction

Chronic mental disorders such as schizophrenia and bipolar disorder are among the leading causes of disability and morbidity and admission to hospital in the local population. Although they are treatable, and in recent decades advances in psychopharmacology have provided better therapeutic options and greater patient stability, these disorders continue to occupy the top spots in global disability statistics.¹

In bipolar disorder the disability is not only associated with affective episodes and residual symptoms; studies show that, even during periods of euthymia, patients have poor cognitive performance in areas such as attention, executive function and memory.2, 3, 4, 5 Moreover, it is argued that lifestyle, personality characteristics and ways of coping with mental illness also have an important influence on the demand for care from emergency services, hospital admission and length of stay, and adherence and response to treatment.⁶ The situation is similar in patients with schizophrenia, many of whom suffer from persistent residual positive and negative symptoms which are directly related to work-related, social and family disability.7, 8

The knowledge accumulated up to now on bipolar disorder and schizophrenia tells us that there are alterations in multiple dimensions of the human being, and the complexity of patients requires more comprehensive complementary strategies than those currently available. One answer to this need is to offer patients with bipolar disorder and schizophrenia a multidisciplinary intervention programme in which, in addition to pharmacological treatment, patients have adequate intervention in psychoeducation, psychology, neuropsychological rehabilitation, occupational therapy, family therapy and general medicine, with a treatment plan tailored to individual needs.9, 10, 11 Although many of these therapies have been evaluated separately and have proved useful in both disorders, there is little information on the effectiveness of multimodal intervention (MI) programmes compared with traditional intervention (TI) in the different therapeutic targets.

Family dynamics is one of the most important domains in the therapeutic approach and evaluation of patients with chronic mental illness,¹² and it is known that there is a bidirectional interaction between patients and their families. The presence of a patient with schizophrenia or bipolar disorder interferes with many aspects of family dynamics, generating a need for support, counselling and psychoeducation on the disease and treatment, as well as indications about how to relate to the patient.13, 14, 15, 16 The role of the family is essential, since the lived experience and the proximity with the patient can provide the information necessary to define a work plan and talk about the relationships that exist within the family.¹⁷

Studies of patients’ family environments have focused on expressed emotion (EE), that is, individual attitudes or predispositions that facilitate or interfere with interpersonal relationships and constitute a relational process between patients and their relatives.18, 19 Important aspects of EE are criticism and emotional over-involvement. Criticism is defined as a negative filter that distorts how people see themselves and others, and over-involvement is the lack of appropriate emotional boundaries between the members of a family. These emotions are highly correlated with the worsening of symptoms and the need for hospitalisation.20, 21, 22 The investigation of new strategies with which to address these critical points is necessary in order to help improve patients’ functionality and prognosis.

The mental health programme focusing on reducing the burden, suffering and social spending in mental illness (PRISMA) was designed with several objectives, one of which is the aim to describe the level of expressed emotion (criticism and over-involvement), burden and functioning in a population of patients with bipolar disorder and schizophrenia, and to assess the efficacy of an MI compared with a TI in terms of family functioning and how it is perceived by patients and their carers.