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Psychological edu for families and primary caregivers, a need of the hour: Study 

09 Aug 2021

  • Schizophrenia relapse/readmission linked to high levels of expressed emotion, poor treatment adherence 
BY Ruwan Laknath Jayakody  Since the relapse of schizophrenia and the readmission of patients with schizophrenia to hospital are associated with high levels of expressed emotions – particularly hostile attitudes towards the illness and the patient – together with poor adherence to treatment, researchers identify a need for psychological education to be given to families of patients and for family interventions in Sri Lanka in order to reduce high levels of expressed emotion among primary caregivers.  Schizophrenia is a mental disorder involving continuous or relapsing episodes of psychosis, where the patient finds it difficult to determine what is real and not.  This recommendation was made in an original paper on “Expressed emotion, medication adherence and association with disease prognosis in patients with schizophrenia at the Anuradhapura Teaching Hospital” which was authored by A. Ellepola (Consultant Psychiatrist at the same Hospital) and C.A. Abayaweera (Registrar in Psychiatry at the same Hospital), and published in the Sri Lanka Journal of Psychiatry’s 11th Volume’s First Issue on 18 June 2020.  In Sri Lanka, Ellepola and Abayaweera observe, family members play a crucial role in the management of mentally ill individuals.  Expressed emotion is described as the caregiver’s attitudes and behaviours towards a person with a mental illness, and is, as explained in J.M. Hooley and H.A. Parker’s “Measuring expressed emotion: An evaluation of the shortcuts”, characterised by criticism, hostility, and emotional over-involvement. In “Influence of family life on the course of schizophrenic illness” by G.W. Brown, E.M. Monck, G.M. Carstairs, and J.K. Wing, it was found that high levels of expressed emotion have a direct association with the recurrence of a wide range of mental illnesses, in particular, schizophrenia, with significant behavioural deterioration being reported in such patients who live with even minimally hostile relatives.  Ellepola and Abayaweera conducted a cross-sectional descriptive study in the psychiatry wards of the same hospital using the convenience sampling method to select 170 consecutive patients. These participants were recruited if they had been diagnosed as having schizophrenia by a consultant psychiatrist, according to the diagnostic criteria of the World Health Organisation’s International Classification of Diseases – 10th Revision’s Classification of Mental and Behavioural Disorders, were admitted to the psychiatry ward with a relapse, and were above 18 years of age. Remission was determined on discharge by a consultant psychiatrist. Patients with comorbid learning disability, those with bipolar affective disorder (a mood disorder involving periods of depression and periods of abnormally elevated mood), schizoaffective disorder (a mental disorder involving abnormal thought processes and unstable mood), dementia (a syndrome involving the deterioration of the cognitive function – the ability to process thought), and patients living on their own without family members or guardians, were excluded.  A questionnaire-based survey was conducted among the patients after they had recovered and improved from the acute relapse, but prior to their discharge from the hospital, and with their relatives, separately and confidentially, using the client and relative versions of the Level of Expressed Emotion (LEE) questionnaire, which is a scale with 60 items and is a self-reported questionnaire with four subscales for intrusiveness, emotional response, attitude toward illness, and tolerance and expectations. Adherence to medication was assessed by the pill count and clinical assessment by the psychiatrist.  With regard to the patients: in terms of their biological sex, the majority were female (88 - 51.8%) followed by male (82 - 48.2%); age-wise, the mean age was 40.1 years from a range of 18-83 years (further, 72.3% were between 21-50 years of age with 25.6% males being between 21-30 years of age while 31.81% females were between 31-40 years of age); in terms of the marital status, the majority were married (81 - 47.6%) followed by those who were unmarried (60 - 35.3%), separated or divorced (17 - 10%), in a relationship (6 - 3.5%) and widowed (6 - 3.5%); in terms of the occupational status, the majority were unemployed (115 - 67.6%) while 55 (32.4%) were employed; in terms of ethnicity, the majority were Sinhalese (159 - 93.5%), followed by Muslims and Moors (10 - 5.9%), and Tamils (1 - 0.6%); in terms of their level of income, the majority earned between Rs. 10,000-25,000 (73 - 42.9%), followed by those who earned less than Rs. 10,000 (52 - 30.6%), Rs. 25,000-50,000 (37 - 21.8%) and less than Rs. 50,000 (8 - 4.7%); and in terms of the level of education, the majority had studied from Grade 5 to 11 (59 - 34.7%), followed by those who had the General Certificate of Education (GCE) Ordinary Level (50 - 29.4%), no education or below Grade 5 (39 - 22.9%), GCE Advanced Level (15 - 8.8%), and graduate (7 - 4.1%).          With regard to the primary caregiver, in terms of the biological sex, the majority were female (103 - 60.6%) followed by male (67 - 39.4%); age-wise, the mean age was 50.62 years from a range of 22-80 years; and in terms of the marital status, the majority were married (138 - 81.2%) followed by those who were widowed (10 - 5.9%), unmarried (9 - 5.3%), divorced or separated (7 - 4.1%), and in a relationship (6 - 3.5%). The main primary caregiver was the mother (50 - 29.4%), followed by the spouse (45 - 26.5%), brother or sister (23 each - 13.5% each), father (11 - 6.5%), other (11 - 6.5%), and friend (7 - 4.1%). The majority of the patients were living with the primary caregiver (126 - 74.1%) while 44 (25.9%) were not. With regard to the duration of the number of hours of contact between the patient and the primary caregiver, the mean number of hours during weekdays was 9.64 from a range of up to 24 hours while during weekends, it was 22.92 hours from a range of up to 48 hours.   The mean duration of the illness was 12.02 years.  The mean number of lifetime relapses experienced by the patients was 6.18 while the mean number of days between relapses was 872.31.  The majority had poor adherence or showed non adherence to treatment while 66 (38.8%) had satisfactory adherence to treatment.  Low levels of expressed emotion was seen in a majority of the patients’ families (99 - 58.2%). Ellepola and Abayaweera observed that this prevalence of the level of expressed emotion being low may be due to the socio-cultural background.  The mean number of relapses due to low levels of expressed emotion along with satisfactory or poor levels of adherence to treatment was 3.38 and 4.60, respectively. The mean number of relapses for high levels of expressed emotion along with satisfactory or poor levels of adherence to treatment was 5.29 and 10.26, respectively. In short, the mean relapse rate was significantly higher among patients experiencing high levels of expressed emotion and poor adherence to treatment, compared to patients experiencing low levels of expressed emotion and having good adherence to treatment.  There was found a significant association between adherence to medication, the level of expressed emotion and the number of relapses. A statistically significant difference in the mean number of relapses for those with high levels of expressed emotion and poor adherence to treatment was also indicated but not for those with low levels of expressed emotion.  Further, expressed emotion showed a statistically significant prediction of the number of relapses, while it was found that only attitudes towards the patient added statistically significantly to this prediction.  When it was considered as to whether the biological sex, the duration of the illness, adherence to treatment, or living with the primary caregiver predicted relapse, the results showed the duration of the illness and poor adherence to treatment adding statistically significantly to the prediction of relapse, whereas the biological sex and living with the primary caregiver did not statistically significantly predict relapse.  Interpreting the findings, Ellepola and Abayaweera, citing Leff et al., noted that hostile attitudes towards mental illness, and towards patients, are relatively unmodified by diverse cultural factors. However, the researching duo concluded that the manner in which cultural and geographic differences could contribute to high levels of expressed emotion requires further study.  Statistically speaking, according to Hooley et al., “Expressed emotion and psychiatric relapse: A meta-analysis” by R.L. Butzlaff and J.M. Hooley, and “The influence of family and social factors on the course of psychiatric illness: A comparison of schizophrenic and depressed neurotic patients” by C.E. Vaughn and J.P. Leff, patients with schizophrenia who return home from hospital to live with family exhibiting high levels of expressed emotion are two times more likely to relapse, compared to patients who return home to families showing low levels of expressed emotion. Furthermore, studies conducted in North India (“Expressed emotion and schizophrenia in North India” by J. Leff, N.N. Wig, D.K. Menon, H. Bedi, L. Kuipers, A. Ghosh, A. Korten, G. Ernberg, R. Day, and A. Jablensky), Japan (“Expressed emotion and the course of schizophrenia in Japan” by S. Tanaka, Y. Mino and S. Inoue), and Pakistan on expressed emotion and the course of schizophrenia, have, whilst confirming the association between the relapse of schizophrenia and high levels of expressed emotion in the family, noted that only the association between hostility (an expression of anger) and criticism, and relapse was statistically significant as being the main contributory components for relapse. This is also indicative, according to the Japanese study in question, of the role played by emotional over-involvement in relapse. Simply put, in the case of schizophrenia, high levels of expressed emotion significantly predicted relapse compared to those schizophrenic patients who experienced low levels of the expressed emotion.   

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